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Cases Report “headaches” (1)

Cases Report “headaches” (1). Dr David Tran A&E depatement Medical meeting 1 st september 2010. First consultation at FVClinic. Cambodgian man 34 years old, coming for headaches and fever for 5 days. Pas history of hepatitis B with AgHBs & Ag HBe positives (treatment with Tenofovir)

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Cases Report “headaches” (1)

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  1. Cases Report “headaches” (1) Dr David Tran A&E depatement Medical meeting 1st september 2010

  2. First consultation at FVClinic • Cambodgian man 34 years old, coming for headaches and fever for 5 days. • Pas history of hepatitis B with AgHBs & Ag HBe positives (treatment with Tenofovir) • Went to Cambogian clinic: dengue fever and malaria tests negative > symptomatic treatment. • Five days later went to HCM city FVClinic because no improvement: head CT scanner normal > treatment for migraine (Sumatriptan + Zoloft + Lexomil) and add Aspirin because no improvement...

  3. Consultation in A&E FVH • Pulse 84/min, BP 100/60, Temp. 37,8, RR 20/min, SpO2 98, Pain score 8/10, G. 15 • Clinical exam: Alert but headaches +++, no nuchal rigidity, no neurodeficit, cranial nerves normal (occulomotricity normal) • No nausea and no vomiting • No abnormality at auscultation, no pain at abdominal palpation. • No rash, no petechia and no purpura

  4. Blood tests results • WBC 12900 (75 % neutrophile) • CRP 84mg • Dengue serology negative IgM & IgG • Malaria test negative • Lumbar puncture: clear liquid, no blood, no tension

  5. Cephalorachidian liquid analysis

  6. LCR chemical results

  7. LCR interpretation

  8. Discussion • Persistant headaches, resistance to symptomatic treatment • Head CT scanner normal • Hypothesis: sub-arachnoid hemorrhage, meningitis, cerebral thrombophlebitis, migraine, tension headaches? • T 37,8 and CRP 84mg • Lumbar puncture: lymphocyte meningitis without hyperproteinorachia nor hypoglycorachia > viral meningitis

  9. Main virus responsable for acute meningitis

  10. Conclusion • If serious and persistant headaches, don’t evocate the diagnosis of migraine without ruling out other serious diseases • Serious headaches associated with mild fever and CRP increased should incite us to perform lumbar punction(after rule out dengue fever and checked platelets). • Viral meningitis without sign of encephalitis(global and focal neurologic findings include encephalopathy, delirium, aphasia, cranial nerve deficits, and hemiparesis) • Favourable outcome after 48h with symptomatic treatment (patient discharged)

  11. Migraine criteria (IHS 1988) Migraine without aura diagnostic criteria • A.At least five headache attacks lasting 4 - 72 hours (untreated or unsuccessfully treated), which has at least two of the four following characteristics: • 1.Unilateral location • 2. Pulsating quality • 3. Moderate or severe intensity (inhibits or prohibits daily activities) • 4. Aggravated by walking stairs or similar routine physical activity • B.During headache at least one of the two following symptoms occur: • 1. Phonophobia and photophobia • 2. Nausea and/or vomiting

  12. Migraine criteria (IHS 1988) Migraine with aura diagnostic criteria • A.At least two attacks fulfilling with at least three of the following: • 1. One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain stem functions • 2. At least one aura symptom develops gradually over more than four minutes, or two or more symptoms occur in succession • 3. No aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is proportionally increased • 4. Headache follows aura with free interval of at least 60 minutes (it may also simultaneously begin with the aura • B.At least one of the following aura features establishes a diagnosis of migraine with typical aura: • 1. Homonymous visual disturbance • 2. Unilateral paresthesias and/or numbness • 3. Unilateral weakness • 4. Aphasia or unclassifiable speech difficulty

  13. Tension type headache criteria • A. Headache lasting from 30 minutes to seven days • B. At least two of the following criteria: • 1. Pressing/tightening (non-pulsatile) quality • 2. Mild or moderate intensity (may inhibit, but does not prohibit activity) • 3. Bilateral location • 4. No aggravation by walking, stairs or similar routine activity • C . Both of the following: • 1.No nausea or vomiting (anorexia may occur) • 2. Photophobia and phonophobia are absent, or one but not both are present

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