A patient with fever and headache AUTHOR DR. LAU CHU LEUNG, TERRY AUGUST, 2013 HKCEM College Tutorial.

A patient with fever and headacheAUTHOR

DR. LAU CHU LEUNG, TERRY

AUGUST, 2013

HKCEM College Tutorial

2

Triage Notes

▪ 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 ºCTriage Cat 4

Fever & Headache, DDx?

3

Further Hx?

▪ Fever▪ TOCC▪ Pattern▪ Associated symptoms

▪ Headache▪ PQRST▪ Red flags

▪ New onset or change pattern/severity

▪ Worse in morning, after sneezing, straining or coughing

▪ Abnormal neurological findings

▪ 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

Headache Red Flags

4

Physical Examination

▪ No Rash

▪ No neck stiffness, Kernig's sign, Brudzinski's sign

▪ CN grossly normal

▪ Limbs power▪ Left - full▪ Right – grade 3+/5

Fever & Limping - DDx

▪Due to pain…▪Due to weakness…

5

6

Hemiplegia in young patients - DDx

▪ Adults▪ 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

What is this Triad indicates?

Brain Absces

s

Headache

Fever

Focal Neurolo

gy

7

Brain Abscess – Predisposing Factors

▪ Cyanotic congenital heart disease ▪ Right-to-left shunting ▪ Areas of brain ischemia

8

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%)

9

Brain Abscess – Causative Organisms

▪ Bacterial (90%)

▪ Fungal

▪ Parasitic

10

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▪ Nocardia▪ Fungi▪ Mycobacterium tuberculosis▪ Toxoplasma gondii

11

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

12

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 glucose is not lowered

▪ Increase in turbidity of CSF▪ Rise in CSF cell count▪ Decrease in CSF glucose▪ Sudden rise in ICP

CSF features signify rupture into ventricle?

13

Brain Abscess – CT

14

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

15

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

16

Antibiotic therapy without surgical intervention

▪ Can be considered if ▪ 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

17

Antibiotic Therapy

18

Brain abscess – Surgical Management

▪ Depend on▪ Size▪ Location▪ Stage of the lesion

▪ Aspiration or excision

19

▪ Surgical excision is indicated▪ 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

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▪ 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. 20

Brain abscess

▪ Poor prognostic indicators▪ Delayed diagnosis▪ Rapidly progressing disease▪ Coma▪ Multiple lesions▪ Intraventricular rupture▪ Fungal cause

21

▪ Long-term sequelae▪ Motor deficits▪ Seizures (25-50%)▪ Mental retardation▪ Behavior/learning

problems▪ Abscess recurrence

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)22

Thank You