Hot Seat #77: 13 yo M with headache
Posted on: June 13, 2016, by : scott herskovitz
Scott Herskovitz, Inova Children’s Hospital
with Theresa Walls, Children’s National Medical Center
The Case
13 y.o. male presents to the ED with cough, congestion, and coryza for the past 10 days. He went to an urgent care center on day 2 of illness, where he had negative strep, monospot, and flu tests. He presented again to an urgent care center on day 4 of illness with the same symptoms, and at that time he was found to be flu B positive. He reports that by day 5 of illness, his initial symptoms had begun to improve, but at about the same time, he developed occipital headache (4/10), neck pain, and photophobia. He has had intermittent fevers during the past 10 days to 100.6F, but today is afebrile. Over the past 2 days he has also developed nausea and vomiting. He was sent from an urgent care for further evaluation due to possible concern for meningitis.
ROS:
No rash, no changes in behavior, sick contacts, trauma or recent travel
PMH, PSH, FH, SHx all noncontributory
PE: VS 97.4, HR 77, RR 18, BP 112/59, S 99% RA
Well-appearing but uncomfortable in bed with lights off, answering questions normally
PERRL, EOMI, MMM
Neck supple w/ minimal pain on motion but nontender, normal ROM, nontender shotty cervical lymphadenopathy
Chest CTAB, heart RRR, no murmurs or gallops
Abd ND/NT, no masses
Normal sensation throughout, motor 5/5 UE and LE, finger to nose normal, reflexes 2+ and normal gait
Question 1:
You decide the patient is at low risk clinically for meningitis. You treat him for a presumed migraine with toradol, zofran, reglan, and IV fluids. Shortly after administration of reglan, the patient suddenly becomes extremely agitated, altered and combative, requiring multiple people to hold him down.
Question 2:
The patient is given IV Benadryl and multiple doses of Ativan totaling 8mg without change in his mental status. He is then placed in restraints, but continues to thrash about in bed with minimal change in his level of agitation. He remains hemodynamically stable and afebrile.
Question 3:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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I have a question for the group–what do we think is going on with this kid after the Reglan? This doesn’t sound like extrapyramidal symptoms/dystonic reaction. From my understanding (and quick reading), those are distressing but don’t typically give altered mental status and combativeness. Neuroleptic malignant syndrome crossed my mind but typically that doesn’t occur so quickly after the first dose of medicine and has a more insidious onset (plus we don’t have a fever in the ED yet). For these reasons, I ignored Benadryl as an option all together–I don’t think it’s going to be very sedating, I’m not treating EPS as far as I can tell, and it only has the potential to make his agitation worse.
Also, I probably would not tap this child without a CT of his head. I think I’ve seen or heard about too many teenage boys with intracranial abscesses recently that with this story I would want to rule that out first.
Sounds like he’s progressing to an influenza meningo-encephalitis and needs a CT and LP and admission if mental status not at baseline. This is not a story suggestive of intracranial abscess (normal strength, no cardiac or significant sinus disease, etc) nor is it suggestive of white matter disease but it could be complicated by sinus thrombosis.
Good case! First we have to figure out how to manage him acutely, then we can try to figure out what he has. In the immediate setting, benadryl & benzos usually fix just about anything, but not in this case. If this is a reaction to the reglan, Benadryl should work, and it should work fast. So maybe it’s something else. (but we’ll get to that in a minute!) I wouldn’t keep giving benzos if 8mg hasn’t done anything. Sedating with ketamine and/or propofol would be a last resort for me; and intubation isn’t needed currently if his respiratory status is ok. Haldol is an option. As far as I can tell, it’s been studied fairly well in children and can be given IM/IV. However, it can have some serious side effects that we’d have to monitor for and be prepared to deal with, such as prolonged QT and arrhythmias. (The newer 2nd-generation antipsychotics don’t have as many bad side effects, but most are not available IM/IV) Other options might be a muscle relaxant like flexeril (cyclobenzaprine), but I wouldn’t think this would be too effective in light of what’s been given so far.
But what does this patient have? We know that he was recently positive for Flu B. He could have influenza-related encephalopathy/encephalitis. In one study from Japan, older children with flu encephalitis were more likely to have flu B and to have altered mental status instead of seizures as their initial presentation. Influenza is also associated with Reye’s syndrome. Symptoms include a rapidly-progressive encephalopathy that begins several days after recovery from a viral illness (like our patient). These patients also have elevated transaminases and elevated ICP.
When I read “cough, congestion, coryza” in the first sentence of his presentation, I couldn’t help but think of measles. He has some things that support measles, but some that go against it. Against it are the lack of high fevers and no rash. However, the 3 C’s, as well as photophobia & headache definitely go along with it. Immunocompromised patients may not get a rash with measles and are at increased risk for complications such as pneumonia & encephalitis. Has this patient been tested for HIV?
Without high fevers and/or localizing neurologic signs, I agree with others that an intracranial abscess is less likely. And with stable VS, neuroleptic malignant syndrome is also unlikely.
So now we’re left with a very broad differential of acute encephalopathy, which is really a diagnosis of exclusion. He could have a CNS infection or mass, ICH, or sagittal sinus thrombosis. Other things on the list would be drugs/ingestion (especially one of the newer synthetic drugs), electrolyte abnormalities (I know, also broad but easy to check for), hepatic failure, or uremia. A likely diagnosis in our patient is postinfectious encephalomyelitis, or acute disseminated encephalomyelitis (ADEM). His prior clinical course and acute symptoms of HA, vomiting, and rapid progression of encephalopathy go along with ADEM.
To get to the diagnosis, he definitely needs a head CT and an LP, in that order. Screening bloodwork would also help direct our workup. I’d be generous with labs, to include HIV, measles titers, cmp, cbc with diff, and UA/Utox. Our LP should include an opening pressure if possible and fluid should be sent for the usual bacterial studies as well as more unusual viral pathogens. (I might make a quick call to ID on this one to make sure I don’t miss anything)
Once we have our head CT & preliminary CSF fluid results, as well as some repeat neuro exams to determine if and how rapidly his neuro symptoms are progressing, we can direct our admission and therapy accordingly.
He is acutely encephalopathic and afebrile, so would obtain a head CT before LP in consideration of the ddx mentioned above.
The additional labs that came to mind in reading this vignette are: NH4 with the LFTs, an ECG to look for evidence of ingestion, and both an arboviral panel and mycoplasma with the CSF testing (mycoplasma is a mimicker of many viral illnesses and has a wide array of clinical presentations). Finally, double check on travel, as this may broaden the differential of infections.
Not sure what led to the initial diagnosis of migraine, given 10 days of intermittent fevers. The fever certainly makes me think of alternative diagnoses, such as lyme or viral meningitis. He could certainly have had flu initially and now have a second unrelated diagnosis, albeit that is always less likely. I would have initially done an LP, although if he then became encephalopathic/ aggressive during the LP, that would have been a real bummer for all involved 🙂