Morning Report

Katherine MacDonald, PGY3

11/4/2013

Chief Complaint

13 yo otherwise healthy male presents at urgent care clinic with headache and vomiting

HPI
13Y old male with 3 days of headaches, 2 days of vomiting , nausea, chills and right ear pain.

The headache and vomiting worsened in the last 24 hours 8 episodes of emesis in the last 24 hours. No Diarrhea Nothing to eat for the last 3 days. Markedly decreased liquids + Sore Throat. No cough, congestion, visual changes, seizures, rashes or fevers. + chills and sweats though with possible tactile fevers. There has been no blood in the stool.

PMH/FH/SH
PMH: undescended testicle PSH: orchipexy IMMS: UTD Meds: None regularly NKDA FH: No sick contacts. SOCIAL HISTORY: Lives with parents. Went to Boy Scout camp earlier in summer and Yellowstone 2 weeks prior to urgent care visit.

Physical Exam
Vitals: T 97.2 F HR 91 BP 110/ 69 RR 18 SpO2 100% GEN: Not well appearing, tired and pale, alert and oriented HEENT: NC/AT, PERRL, EOMI. Eyes not sunken with no injection or discharge. Ears TM's with normal landmarks No rhinorrhea. Normal pharynx, Neck Supple. No cervical LAD. No cervical spine tenderness. Tenderness to palpation on the upper trapezius muscles. Lungs: Clear to auscultation Heart: RRR No murmur, gallop, or Rub Abd: Soft, diffuse tenderness, no guarding or rebound, Hyperkinetic BS, no HSM. Skin: No rash. Neuro: Normal Speech and Gait, CN intact

Urgent Care Course:

Zofran, Torodal, and 2L IVF Headache improved, Decreased Dizziness Did not Tolerate PO fluids (continued Emesis) POC iStat: Nml BMP, Glu 177

Transfer to local hospital. ER notified. IV secured.

Events Leading to Admission

Went home Early in morning, had altered mental status, unusual behaviors, and confusion Presented at local hospital and transferred to childrens hospital Here on exam: afebrile, agitated, did not follow commands, no meningeal signs, no focal neuro deficits, brisk CRT

Differential Diagnosis:

Neuro:
Intracranial Mass Intracranial Hemorrhage (Subarchnoid) Sinus Venous Thrombosis Vasculitis Meningitis Encephalitis Brain Abscess/Subdural Empyema Sinusitis Gastroenteritis

Infectious:

Ingestions Metabolic (hypoglycemia, hyponatremia, acidosis) Trauma Shock:

Septic, Hypovolemic, or Cardiac (Myocarditis)

Work Up
CBC: 13.9 17>-----<224 37 146/113/11 ----------------< 132 3.7/21 /0.58 Protein 7.4 Albumin 4.2 Alk Phos 146 (H) ALT 25 AST 18 N 84, L 4.3, M 10

CSF: WBC 4213 (N 93, L 1) RBC 311, Glucose 41, Protein 195 CSF Enterovirus, West Nile, CMV, HSF Negative CSF Culture: Negative (not pretreated) VBG 7.42/35/23/1 Step Clx Neg Blood Culture Neg Sinus Respiratory Cultures: ( R and L Sphenoid) 3+MRSA CT Head w/o Contrast: Sphenoid, Ethmoidal Opacification, Mild Brain Edema without Herniation MRI Brain w/ and w/o Contrast: Basilar Infarction in both cerebral hemispheres, early subdural empyema, opacification of the sphenoid and ethmoid sinuses. No brain abscess or cavernous venous thrombosis. Mucous retention cyst in R maxillary. MRA: Narrowing of distal internal carotid arteries and anterior and middle cerebral arteries.

Imaging

Anatomy Review

Diagnoses

MRSA sphenoid/ethmoidal sinusitis

Bacterial meningoencephalitis
Cranial nerve III palsy Bilateral basilar infarcts Subdural empyema

Hospital Course

On Admission:
CT Vancomycin, Ceftriaxone, Acyclovir Decadron (concern for pneumococcal meningitis)

HD 2:
Declining mental status and left ptosis and dilated pupil. Intubated, Head CT, MRI/MRA MRI/MRA showed bilateral basilar infarcts and small subdural empyema ENT surgically drained sinuses ID, Neurology, and Neurosurgery Consulted Vancomycin, Ceftriaxone, Flagyl

HD 3:
Started ASA Vancomycin and Meropenum

HD 4:
Extubated

Continued Course
Discharged 3.5 weeks later Remained on antibiotics ~6 weeks Continued on ASA Behavior and cognitive difficulties (impulsive, inattentive, memory difficulties) No headaches, seizures, vision difficulties Recently returned to school

SINUSITIS

Sinusitus: Diagnosis

Include
Age 1-18yo Without CF, PCK, Immunodeficiencies, Anatomic abnormalities

Acute Sinusitus
Context of a child with a URI/ Symptoms Persistent Illness (cough, rhinorrhea) for 10 day Severe Onset: Fever >39 and purulent discharge 3 days Worsening Course or new onset of Symptoms

Supportive H and P:
Bad breath, Fatigue, Headache Physical Exam: Turbinates? Percussion? Transillumination?

Wald EW et al. 2013

Sinusitis vs. URI vs. Allergic Rhinitis

Viral URI:
Rhinorrhea, congestion, cough Fever and constitutional symptoms early in course Usually 5-7 day

Wald EW et al. 2013

Sinusitis vs URI vs Allergic Rhinitis

Allergic Rhinitis
Family History of Atopy Seasonality or exposures Itchy eyes Physical Exam: Nasal crease, allergic shiners, Cobble-stoneing, pale nasal mucosa

Wald EW et al. 2013

Imaging

No need unless complications are suspected

If so, obtain a CT and/or MRI with Contrast of paranasal sinuses

Wald EW et al. 2013

Treatment

Acute onset or worsening course: TREAT

If persistent symptoms: EITHER treat OR Observe for more3 days

Treatment: Amoxicillin or Augmentin

Wald EW et al. 2013

Pathogens and Treatment Choice

S. Pneumoniae (30%), Nontypeable H. Influenza (20%), M. Catarrhalis (20%)

Many S. Pneumoniae are not susceptible to PCN 10-42% H Flu and 100% M Catarrhalis are Beta Lactamase Producing Risk Factors for amoxicillin resistance
Daycare, < 2yo, Antibiotics in the last 4 weeks.

Wald EW et al. 2013

Pathogens and Treatment

Amoxillin 45mg/kg/day BID 10 days

<10% resistance in community Mild to Moderate Illness No risk factors for resistance

Amoxillin 80-90mg/kg/day BID

>10% resistance Augmentin 80-90mg/kg/day BID ( IDSA first choice) Moderate to Severe Risk Factors

Ceftriaxone 50mg/kg IM/IV

If cannot tolerate PO

Cefdinir, Cefuroxime
PCN Allergic

Wald EW et al. 2013

Follow up

Reassess after 3 days

Most will have symptom improvement if not resolution within 3 days

Wald EW et al. 2013

Complications
Orbital: Periorbital Cellulitis Orbital Cellulitis Spread from Ethmoid sinus Most Common complication <5 yo

Intracranial: Suspect with very severe headache, photophobia, seizures, focal signs, altered mental status Subdural Empyema, Epidural Empyema, Cavernous Sinus Thrombosis, Brain abscess, meningitis Adolescent Males highest risk Bone: Pott Puffy Tumor (Osteo of frontal bone) Mucoceles (Chronic Inflammatory lesions)
Wald EW et al. 2013, Pappas DE 2011

Complications
Symptoms and Signs at PCH Retrospective study (2000-2004) 12 identified w/ Sinogenic Intracranial Empyema Avg Age 11.5yo Equal Male and Female Signs Labs

Symptoms

Fever (11) Headache (10) Nausea/Vomiting (7) AMS (5) Congestion/rhinorrhea (3)

Abn Neuro Exam (9) WBC: 10-21, Median17 Potts Puffy (4) CRP : 0.7-84 Orbital Cellulitis (3) ESR: 17-123 LPs (4): WNL Glucose >120 in 4 pt

Adame, N 2005

References

Wald ER, Applegate KE, Bordley DH et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1-18 Years. Pediatrics 2013;132; e262.

Pappas DE, Hendley JO. Sinusitis. Nelson Textbook of Pediatrics. 19th Ed. 2011. p14361438. Adame N, Hedlund G, Byington CL. Sinogenic Intracranial Empyema in Children. Pediatrics 2005; 116; e461.