a patient with fever and headache author dr. lau chu leung, terry august, 2013 hkcem college...
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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?
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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
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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…
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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
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Brain Abscess – Predisposing Factors
▪ Cyanotic congenital heart disease ▪ Right-to-left shunting ▪ Areas of brain ischemia
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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%)
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Brain Abscess – Causative Organisms
▪ Bacterial (90%)
▪ Fungal
▪ Parasitic
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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
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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
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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?
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Brain Abscess – CT
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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
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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
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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
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Antibiotic Therapy
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Brain abscess – Surgical Management
▪ Depend on▪ Size▪ Location▪ Stage of the lesion
▪ Aspiration or excision
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▪ 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
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▪ 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