1. A patient with fever and headache AUTHOR 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 ºC Triage Cat 4 Fever & Headache, DDx? 2

3. 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 3

4. Physical Examination ▪ No Rash ▪ No neck stiffness, Kernig's sign, Brudzinski's sign ▪ CN grossly normal ▪ Limbs power ▪ Left - full ▪ Right – grade 3+/5 4

5. Fever & Limping - DDx ▪ Due to pain… ▪ Due to weakness… 5

6. 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 6

7. What is this Triad indicates? Brain Abscess HeadacheFever Focal Neurology 7

8. Brain Abscess – Predisposing Factors ▪ Cyanotic congenital heart disease ▪ Right-to-left shunting ▪ Areas of brain ischemia 8

9. 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%) 9

10. Brain Abscess – Causative Organisms ▪ Bacterial (90%) ▪ Fungal ▪ Parasitic 10

11. 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 11

12. Brain Abscess – Investigations? ▪ ESR & WCC ▪ Not reliable ▪ Blood culture ▪ Positive in 15-30% (p articular 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 12

13. 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? 13

14. Brain Abscess – CT 14

15. 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 15

16. 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 16

17. 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 4 th Ed 17

18. Antibiotic Therapy 18

19. Brain abscess – Surgical Management ▪ Depend on ▪ Size ▪ Location ▪ Stage of the lesion ▪ Aspiration or excision 19 ▪ 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

20. 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

21. Brain abscess ▪ Poor prognostic indicators ▪ Delayed diagnosis ▪ Rapidly progressing disease ▪ Coma ▪ Multiple lesions ▪ Intraventricular rupture ▪ Fungal cause 21 ▪ Long-term sequelae ▪ Motor deficits ▪ Seizures (25-50%) ▪ Mental retardation ▪ Behavior/learning problems ▪ Abscess recurrence

22. 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 (7 th Ed) 22

23. Thank You