A patient with fever and headache

1. HKCEM College Tutorial A patient with fever and headache aUTHOR Dr. Lau chuleung, terry August, 2013

2. 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

3. Further Hx? Headache Red Flags • 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 orpersonality • New headache for age > 50 • HI • Night time awakening • History of cancer or immunodeficiency

4. Physical Examination • No Rash • No neck stiffness, Kernig's sign, Brudzinski'ssign • CN grossly normal • Limbs power • Left - full • Right – grade 3+/5

5. Fever & Limping - DDx • Due to pain… • Due to weakness…

6. Hemiplegia in young patients - DDx • Paediatrics • Congenital hemiplegia • Viral infections - herpes simplex virus, enterovirus, measles, herpes zoster vasculitis • Alternating hemiplegia • Avellis syndrome • Alternating hemiplegia of childhood • Delayed • Chickenpox • Adults • CVA - hypercoagulable states, collagen • Neoplasm • Vascular diseases • Hypoglycaemia • Migraine • Brain abscess • Spinal cord injury

7. What is this Triad indicates?

8. Brain Abscess – Predisposing Factors • Cyanotic congenital heart disease • Right-to-left shunting • Areas of brain ischemia

9. 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%)

10. Brain Abscess – Causative Organisms • Bacterial (90%) • Fungal • Parasitic

11. Brain Abscess - Causative Organisms • Post-traumatic • Streptococci or Enterobacteriaceae • Cyanotic congenital heart disease • Haemophilusaphrophilus • Endocarditis or prolonged bacteraemia • S. aureus, streptococci • Conditions producing metabolic acidosis (DM) • Rhinocerebralmucormycosis • Immunocompromised hosts & HIV • Nocardia • Fungi • Mycobacterium tuberculosis • Toxoplasma gondii

12. 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

13. Brain abscess - CSF examination CSF features signify rupture into ventricle? • 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

14. Brain Abscess – CT

15. 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

16. 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

17. 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 antibiotictherapy (4 – 6 weeks) • IMPACT 4th Ed

18. Antibiotic Therapy

19. Brain abscess – Surgical Management • 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 • Depend on • Size • Location • Stage of the lesion • Aspiration or excision

20. 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.

21. Brain abscess • Long-term sequelae • Motor deficits • Seizures (25-50%) • Mental retardation • Behavior/learning problems • Abscess recurrence • Poor prognostic indicators • Delayed diagnosis • Rapidly progressing disease • Coma • Multiple lesions • Intraventricular rupture • Fungal cause

22. 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)

23. Thank You