MORNING REPORT

Chari Larsen, MD PGY-3

HPI
12 yo previously healthy child has been having headaches for approx 2wks. Family notes that the HA started after he was hit in the face with a basketball while playing a game. He has been continuing to have daily HA since that time. The HA has been located in the frontal region and are consistent, occasionally throbbing. He has also been more tired than normal which has been worsening and complaining of being hot and cold but no temperature was taken. They went to their PCP 3 days prior to presentation for the HA's, per mom he was instructed to rest for the weekend and see if things got better (per notes was presuming a concussion). The morning of presentation he was noted to be taking longer to get ready than normal and he was dropping things.

He had difficulty getting his left arm in his coat and a glove on his left hand.
He told mom that his hand felt like it was asleep. He went to school but wasn't feeling well so he called mom to pick him up. He was still having weakness in his left UE and was also noted to have some left sided facial droop. They then brought him to the ED.

HPI
PAST MEDICAL HISTORY: No major or chronic illnesses PAST SURGICAL HISTORY: No surgeries IMMUNIZATIONS: Up to date MEDICATIONS: None regularly ALLERGIES: No known drug allergies DIET: normal for age FAMILY HISTORY: No known chronic childhood diseases. SOCIAL HISTORY: Lives with parents and 1 brother. The primary language spoken in the home is English. Tobacco exposure: No. In the 7th grade. Gets all A's. Plays several sports including football, basketball and soccer.

Physical Exam
Temp 38.2, HR 90, RR 20. BP 140/80. Weight 77.6 kg. GCS 15. GENERAL: Awake, but a little bit tired appearing, not confused or disoriented, seemed to have normal speech. HEENT: No scalp swelling or hematomas. PERRL. No hyphema of either eyeball. No ptosis. No significant swelling. Slight impairment of upward movement of his left eyeball compared to the right, but this seems very subtle. TMs normal. Nares slightly congested. MMM, no intraoral lesions. NECK: No stiffness to flexion or extension. LUNGS: CTAB, no rhonchi, wheezes, grunting, retractions, or nasal flaring. CARDIOVASCULAR: RRR, NS1S2 without murmur, gallop, click, or rub. ABDOMEN: BS+, S/NT/ND, no HSM EXTREMITIES: nontender and show full range of motion without pain. There is no clubbing, cyanosis, or edema. SKIN: Capillary refill of 2 seconds, both distally and centrally. No petechiae, purpura, or jaundice. NEUROLOGIC: mild left facial droop with smiling. decreased strength on his left cheek when asked to puff out his cheeks. Symmetric wrinkling of forehead. Moderately diminished left grip and left biceps strength. Unable to fully supinate his left arm. He has no weakness in his lower extremities. No weakness of his right upper extremity. He has normal reflexes in his knees. He has no truncal ataxia and walks without any ataxia.

Differential Diagnosis
Stroke Vasculopathy Aneurysm PRES Hypertension Complex migraine

Brain tumor
Trauma with resultant hematoma
Subdural hemorrhage Epidural hemorrhage

Meningitis
Sinus venous thrombosis Sinusitis w/ intracranial extension

Facial fracture with nerve entrapment

Labs
Urine drug screen - negative Serum drug screen - negative CBC - WBC 24.7 (B4, N90, L3), Hct 34.3, Plts 487 CRR - 25.9

ESR - 101
CMP - Na 132, K 3.8, Cl 93, CO2 22, BUN 10, Cr 0.58, Glu 136, Ca 8.7, Prot 7.8, Alb 3.4, Bili 1.3, Alk Phos 264, ALT 306, AST 89 Fibrinogen - 848 PTT - 32 PT/INR - 14.9/1.2 Blood Culture - NGTD

Imaging
CT of Head - Extra-axial mixed attenuation fluid collection overlying the right frontal lobe with local mass effect. Major diagnostic considerations include epidural hematoma versus epidural empyema/abscess. MRI of Brain - 1. Extensive right frontal parietal subdural complex fluid collection with robust dural and leptomeningeal enhancement to strongly suggestive of empyema. There is extension into the interhemispheric fissure. A small epidural fluid collection thought to represent empyema is also seen and conforms to the finding of concern on CT. No underlying cerebritis is detected. 2. Extensive paranasal sinus inflammatory changes on the left with air-fluid levels in the frontal and maxillary sinuses. 3. Segmental dural sinus thrombosis of the middle portion of the superior sagittal sinus.

Initial Hospital Course

In the emergency department, he was placed on the stoke protocol. Neurology was consulted. Imaging obtained. Neurosurgery was then consulted and decided to bring him to the OR for drainage of the empyema. He got vancomycin, flagyl, keppra and rocephin in the ED and OR. ENT was also consulted for drainage of the sinusitis. In the OR, neurosrugery performed a right hemicraniotomy and washed out the right sided empyma. There was some brain swelling so the bone flap was left out. ENT then drained the left maxillary, frontal and ethmoid sinuses. There was an EBL of 500cc, he got 2500cc of crystalloid, and 67mg mannitol. He was extubated prior to arrival to the ICU. While in recovery he became hypertensive so 10mg of labetalol was given as well.

How is he doing now?

Still has bone flap off Had a few seizures but none for several days Has been very thirsty because of the high Na levels we were pushing Gained almost all of his left sided strength back Transferred out of the PICU yesterday

Sinusitis
3 Types of Presentation:
Persistent illness lasting more than 10 days without improvement Worsening course after initial improvement Severe onset (Temp >39 and purulent nasal discharge) for at least 3 consecutive days

Only a minority (6-7%) of children presenting with URI symptoms will fit the criteria of persistence.

No routine imaging is recommended.

If concern for complications should get CT with contrast

Sinusitis
Most common pathogens Strep pneumo, H. influenzae, and Moraxella catarrhallis. First line antibiotics include amoxicillin or augmentin

No recommendation regarding adjuvant therapy

Complications:
Permanent blindness, epidural or subdural empyema, brain abscess, venous sinus thrombosis, meningitis, preseptal or orbital cellulitis, Pott Puffy Tumor, maxillary sinusitis, optic neuritis, subperiosteal abscess, etc. Intracranial complications are more common if previously healthy adolescent males with frontal sinusitis.

Potts Puffy Tumor

Orbital Cellulitis

Brain Abscess

Subdural Empyema

Subdural Empyema
Defined as a collection of pus between the dura and the arachnoid space Can be a complication of sinusitis, mastoiditis, meningitis, sepsis, or direct extension from osteomyelitis
Worldwide otitis media/mastoiditis are the most common causes of subdural empyema

If from sinusitis it is often from the frontal sinus. Direct or indirect extension.
Indirect extension is more common. Thrombophlebitis spreads in a retrograde manner through the valveless diploic veins in the area.

Subdural Empyema
Often polymicrobial in nature
Neurosurgery recommends Ceftriaxone, Vancomycin, and Flagyl for antibiotic coverage.

Dominant clinical feature is swift neurological deterioration.

Common signs & symptoms include:

Confusion, drowsiness, nausea, vomiting, cranial nerve deficits, headache, fever, meningismus, seizures, hemiparesis, and focal neurological deficits. Can lead to increased ICP, cerebral edema, diffuse cerebritis, seizure activity, sinus venous thrombosis, and infarction.

Mortality rate is ~20% Neurological impairment in 25-30% of patients

References
Index of Suspicion (Case 2), Pediatrics in Review. Vol 25, No. 6, June 2004. Acute Bacterial Sinusitis in Children. Pediatrics in Review. Vol 34, No 10, October 2013. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics. Volume 132, Number 1, July 2013.