CPC Anthony Catapano, DO EM Clerkship Director St. Joseph’s Regional Medical Center Paterson, NJ

1. CPC Anthony Catapano, DO EM Clerkship Director St. Joseph’s Regional Medical Center Paterson, NJ October 12, 2014

3. Welcome to Caesar’s Palace

4. “This isn’t the Real Caesar’s Palace, is it?” “What do you mean?” “Um, did Caesar live here?”

5. “Vegas, baby. Vegas!” Trent: “We got to get you out of Dodge. We’re going to Vegas tonight.” Mike: “What are you talking about?” Trent: “Vegas. Las Vegas!” Mike: “What are you talking about? When are we going to Vegas?” Trent: “We’re going tonight. You bring something nice to wear.” Mike: “I’m not going to Vegas!”

6. “Alright, listen. I took out $300…” “…but I’m only betting with $100.”

7. I Also Think about Foreheads

8. The Case – Chief Complaint • 19 year old with forehead swelling for two weeks

9. What I Know from the HPI • Complains of occasional headaches • Occasional fevers • No neurological symptoms, no vision changes • Treated at multiple institutions for sinusitis • Sinus pressure, nasal discharge, nasal congestion • Several courses of antibiotics – including Levaquin

10. What I Don’t Know from the HPI • What other antibiotics were taken? • Recent travel around the states • Any travel outside the US? • Student. Exchange student? • Immunizations up-to-date? • Cancer history in mother • Pertinent? What kind?

11. What I know from the Exam • VS: BP: 113/71, HR: 81, RR:16, O2: 97% RA, T: 97.6 F • PE: • HEENT: 6 cm X 10 cm boggy swelling with fluctuance and tenderness present on the forehead. • No erythema present, no warmth • Throat: No exudates, but yellow drainage on posterior pharynx • Neuro: Normal

12. Labs • CBC: Normal WBC: 9 Hgb: 14.2 Hct: 41.5 Plt: 242 Diff: N: 71, L: 19, M: 7 • SMA-7: Normal • Na: 142 • K: 3.6 • Cl: 104 • HCO3: 31 • BUN: 13 • Cr: 1.08 • Glu: 84 • ESR: 37 • Slight Elevation (0-10) • Non-specific

13. CT

14. CT

15. CT

16. “Please Clinically Correlate” Sincerely, your favorite radiologist/neuroradiologist

17. Differential Diagnosis • Hematology-Oncology • Lymphoma • Langerhan Cell Histiocytosis • Dermoid cyst • Infectious • Tuberculosis • Fungal • Aspergillus • Mucormycosis • ENT • Frontal Sinus Mucocele • Pott’s Puffy Tumor • Trauma • Hematoma • Skull fracture • Leptomeningeal Cyst • Recent craniotomy/sinus surgery • Dermatology • Abscess/MRSA • Sebaceous Cyst/infected sebaceous cyst • Lipoma • Rheumatologic • Granulomatosis with Polyangiitis (Wegener’s Granulomatosis)

18. Trauma • Hematoma • Skull fracture • Leptomeningeal Cyst • Recent craniotomy/sinus surgery • Not Mentioned in HPI

19. Dermatology • Abscess/MRSA • Sebaceous cyst/infected sebaceous cyst • Lipoma

20. Rheumatologic • Granulomatosis with Polyangiitis (Wegener’s Granulomatosis)

21. Hematology-Oncology • Lymphoma • B cell • T cell • NHL • Langerhan Cell Histiocytosis • Dermoid Cyst

22. Infectious • Tuberculosis • Fungal • Aspergillus • Mucormycosis

23. ENT • Frontal Sinus Mucocele • Pott’s Puffy Tumor

24. Remaining Differentials • Abscess/MRSA • Tuberculosis • Fungal • Aspergillus • Frontal Sinus Mucocele • Pott’s Puffy Tumor

25. CT Abscess Epidural Abscess • With IV contrast

26. CT • With IV contrast

27. Abscess Frontal Sinus Erosion Epidural Abscess Opacification of Right Frontal Sinus

28. Abscess Frontal Lobe edema Stranding Frontal Sinus Erosion

29. Epidural Abscess Abscess Epidural Abscess

30. Remaining Differentials • Abscess/MRSA • Tuberculosis • Fungal • Aspergillus • Frontal Sinus Mucocele • Pott’s Puffy Tumor

31. Wish List • CRP • Rapid HIV • PPD, AFB, CXR • MRI Brain • Biopsy

32. Pott’s Puffy Tumor • 1st described by Sir Percivall Pott – 1869 • Subperiosteal abscess and osteomyelitis • M/C: frontal sinuses • Non-neoplastic complication of sinusitis • Forehead swelling • Typically in adolescents

33. Pott’s Puffy Tumor • Rare • Era of Antibiotic therapy • Typically delayed diagnosis

34. Pathology • Untreated/Improperly treated sinusitis • Chronic sinusitis • Typically bacterial • Polymicrobial, Strep, Staph, anaerobes • Rare: H. influenzae, Proteus, Fusobacterium, Pseudomonas, Bacteroides, Pasteurella multocida

35. Possible Etiologies • In our case, maybe improperly/partially treated • Intracranial epidural abscess • MRSA • Multiple antibiotics • Fungal • Immunocompromised, diabetic, toxic • TB • Traveling, exchange student? Living in college dorms/close quarters? • Non-immunized patient? H. influenzae?

36. Complications • Typically delayed diagnosis • Favors development of complications, which are frequent • 60-100% of patients develop intracranial complications • Intracranial extension • epidural abscess, subdural empyema, intracerebral abscess, cavernous sinus thrombosis, meningitis, cerebritis, seizures, focal neurological deficits, AMS, preseptal cellulitis, orbital cellulitis

37. Pott’s Puffy Tumor with epidural abscess

38. Treatment • Treatment: • Admission • Broad spectrum IV abx • Consult: Neurosurgery, ENT, ID • Surgical debridement • Gram Stain, Culture, aerobic/anaerobic, AFB, Fungal • MRI • PICC line for long-term parenteral antibiotics after discharge