Hot Seat Case #92: 13 yo F with headache
Posted on: April 10, 2017, by : Caleb Ward MD
Caleb Ward MB BChir, Children’s National Medical Center
With Alyssa Abo MD, Children’s National Medical Center
The Case:
A 13 year old female is referred to your ED with two months of intermittent headache, two weeks of non-bilious emesis and now two days of double vision. She describes the headache as a dull ache that is increasing in severity. The headache and emesis do not seem to vary with position or time of the day. She was referred for an outpatient MRI by her pediatrician. Today, the MRI was read as abnormal, so they were contacted by their pediatrician and referred to the ED for a second read of the MRI and further evaluation.
She was born in the US. Foreign travel includes one month in Bangladesh 2 years prior. She has no known TB contacts. No exposure to animals.
She has no known sick contacts.
ROS:
POS: emesis, double vision
NEG: extremity weakness or numbness, fever, rash, easy bleeding or bruising, weight loss
Exam:
Temp 36.5, HR 59, RR 16, BP 106/65mmHg, SpO2 97% on RA, pain 5/10
Tired, appears uncomfortable
PERRL, no jaundice
TMs clear, no pharyngeal erythema
Nl S1S2, no murmur, cap refill < 2s
Lungs clear to auscultation without adventitial sounds
Soft, non distended abdomen, non tender, no organomegaly
No rash
Neurologic exam:
Bilateral CN VI palsy, rest of CNs II-XII intact
Blurred optic disc margins
Extremities have normal tone, 5/5 power, intact fine touch sensation
2+ DTRs with downgoing plantars
Coordination including finger-to-nose and heel-to-shin appears normal
A second read of the MRI shows diffuse nodular leptomeningeal enhancement and mild hydrocephalus. You request that the nurse place an IV and draw some initial labs.
Initial labs show: Hgb 11, WBC 7, Plt 280. Chemistry was unremarkable. LDH and uric acid were normal. A chest radiograph was normal.
Question:
You decide to proceed with an LP in the ED. She is able to cooperate with the procedure after receiving intravenous midazolam. Her headache feels only slightly better after the LP. The following results are obtained:
Opening pressure 55cmH2O
CSF glucose 19 mg/dL
CSF protein 117mg/dL
4 WBCs/mcL
1 RBC/mcL
More Questions:
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This is an interesting case. Diffuse leptomeningeal enhancement has a broad differential.
From https://radiopaedia.org/
“Leptomeningeal enhancement refers to a diffuse or focal gyriform or serpentine enhancement that can be seen in the following conditions:
Diffuse:
1. meningitis, pyogenic meningitis, viral meningitis, tuberculous meningitis (can also be focal)
CNS cryptococcal infection
2. encephalitis
3. tumours: diffuse leptomeningeal glioneuronal tumour, leptomeningeal carcinomatosis (e.g. from carcinoma of breast or lung, melanoma, ependymoma)
4. haemorrhage (e.g. post-subarachnoid)
5. post uncomplicated lumbar puncture (rare, less than 5%)
6. Other: granulomatous conditions
neurosarcoidosis (can also be focal)
post-operative (late finding)
post-traumatic (late finding)
I would try and get more history from patient. Place PPD for TB evaluation.
Where is everyone?
Agree with AA.
To the question of antibiotics or not, one concerning issue is the low CSF glucose. If one has obtained cultures, is there harm in one dose? (other than Jarisch-Herxheimer with spirochetal infections).
Anyone? Ferris?
We won’t be able to join in tomorrow, but keep us posted.