A Horrible Headache

Case ConferenceOctober 1st, 2013

Phuong Dinh, Ben Triche & Alisha Lacour

Headache X 5 days

Chief Complaint

63 year old male with a PMH diverticulitis and Hepatitis B 8 days prior to presentation: has non-bloody, watery

diarrhea that lasted for 2 days and resolved spontaneously. 5 days prior to presentation: Pt developed a sharp, stabbing

left-sided frontal headache, that gradually worsened. Headache was centered over Left temple and radiated up to

his scalp. Pt admitted to fevers, chills, blurred vision, arthralgias, and

myalgias. He denied shortness of breath, cough, neck stiffness,

confusion, N/V, or any other symptoms.

HPI

Diverticulitis Hepatitis B (1971) Chronic Lower Back Pain

Past Medical History

Lasik Back Surgery

Past Surgical History

NKDA

Allergies

Celecoxib 100mg PO BID

Medications

Mother died of heart disease Father died of Alzheimer’s Disease 2 Brothers with Heart disease

Family History

Smokes 1 pack per day for 50 years Rarely drinks on special occasions Denies any illict drug use Lives at home alone Retired massage therapist

Social History

Not up to date on influenza immunization Not up to date on Tetanus immunization No colonoscopy

Health Maintenance

Constitutional: Positive for fever and chills. HEENT: Negative for hearing loss, ear pain, facial

swelling, neck pain, neck stiffness and ear discharge.

Eyes: Negative for pain, discharge, redness and itching.

Reports of blurriness of vision and mild photophobia associated with his headache.

Respiratory: Negative for apnea, shortness of breath and wheezing.

Cardiovascular: Negative for chest pain, palpitations, leg swelling and syncope.

ROS

Gastrointestinal: Positive for diarrhea. Negative

for abdominal pain. Genitourinary: Negative for dysuria and

hematuria. Musculoskeletal: Positive for back pain. Neurological: Positive for headaches. Negative

for dizziness, speech change, focal weakness, seizures, loss of consciousness, facial asymmetry, weakness and numbness.

Psychiatric/Behavioral: Negative for memory loss and altered mental status.

ROS (cont’d)

Physical Exam

Triage Vitals Temperature 98.0° F Blood Pressure 145/80

Pulse 96 Respiratory Rate 16 O2 Sat 93% on RA Height 5’8” Weight 79 kg BMI 26

Exam Vitals Temperature 101.7°

F Blood Pressure

107/79 Pulse 88 Respiratory Rate 16 O2 Sat 96% on RA

GENERAL: Awake, alert, and oriented. Squinting in pain. HEENT: PERRL, EOMI, Left temporal artery more prominent

than right. No tenderness to palpation. Decreased visual acuity of left eye (20/200- left vs. 20/100- right).

NECK: supple, no nuchal rigidity CARDIOVASCULAR: Tachycardic, Regular rhythm. No

murmurs. 2+ radial and DP pulses. RESPIRATORY: No increased work of breathing. No

crackles, rales, wheezes ABDOMEN: Bowel sounds present. Soft. Nontender.

Nondistended. EXTREMITIES: No clubbing, cyanosis, or edema.

Physical Exam

Labs

134 100 123.4 25 1.02

168

Ca 8.5 Mg 1.6 Phos 2.1 TP Alb TB AST ALT ALP6.9 3.2 0.7 101 110 92

11.1 191

14

41.9

N 92 L 4 M 3

93

13.5

HIV – nonreactiveU/A - WNLESR - 72 (0-20)CRP – 23.96 (<0.90)

(<45)(<46)

Electrocardiogram

After initial workup, differential

diagnosis were: Trigeminal Neuralgia Temporal Arteritis

Given his elevated ESR and CRP he was started on prednisone 60mg

Medicine was consulted for admission

ER Course

After Medicine Oncall Team had finished

evaluation of patient and were writing admission orders, the patient spiked a temperature of 105.3, which prompted further workup.

Patient was empirically started on Vancomycin, Ceftriaxone, Ampicillin, and Ciprofloxacin for suspected meningitis

The Medical ICU was consulted Lumbar Puncture was performed

ER Course (cont’d)

CSF Clear Glucose 90 (40-70) Total Protein 49.6 (15-45) WBC 0 RBC 2

Lumbar Puncture Results

Additional Lab Orders placed:

Blood cultures Urine culture Legionella Antigen Hepatitis Panel T spot Rheumatoid Factor ANA Cryoglobulin

Additional Lab Orders

CXR

CTA Chest

CTA Chest

CT Head

The patient was admitted to the ICU

with the following active problems: Sepsis secondary to pneumonia

Continued on Vancomycin, Ceftriaxone, Ampicillin, and Ciprofloxacin

Temporal headache Continued on Prednisone

Hospital Course

The patient was afebrile and was stable for transfer

to the floor. Ophthalmology was consulted for evaluation due to

concern of Temporal Arteritis. A full eye exam was performed showing sharp disc margins, and no evidence of temporal arteritis.

Neurosurgery was consulted for temporal artery biopsy.

Prednisone was continued. Antibiotics were changed to Ceftriaxone and

Azithromycin for Community Acquired Pneumonia.

Hospital Course – day 2

Patient had a temperature of 101.0 overnight. Vancomycin added back to cover for potential

post-viral MRSA pneumonia. Neurosurgery planning for temporal artery

biopsy. Recommending an MRI to better workup abnormality seen on CT imaging.

Hospital Course – day 3

MRI Brain completed Patient’s Legionella Antigen resulted Positive Antibiotics were changed to Ciprofloxacin 400

IV q12 This was selected secondary to cost of

medication

Hospital Course – day 4

MRI Brain

MRI Brain

MRI Brain

MRI Brain

Films reviewed with Neurosurgery. Pt has

cavernous malformation in Left basal ganglia. This could not be removed safely because of its location in eloquent brain. It was recommended to repeat MRI in 3 months and follow up in Neurosurgery clinic for follow-up.

Neurology evaluated the patient who believed that the patient has Trigeminal Neuralgia and recommended Carbamazepine.

Hospital Course

Patient was continued on IV Ciprofloxacin for 2

more days and then discharged on Ciprofloxacin 750mg PO BID x 14 days.

He continued Carbamazapine outpatient for his headaches and was given follow up with Neurology.

Repeat MRI scheduled for 3 months from discharge.

Hospital Course

Legionella Pneumonia Trigeminal Neuralgia

Diagnosis

Thank You