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Man with headache and altered mental status
  1. Christiana K Prucnal1,2,
  2. Paul S Jansson3,4
  1. 1 Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
  2. 2 Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  3. 3 Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
  4. 4 Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Paul S Jansson, Department of Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA; pjansson{at}


Presentation An 83-year-old man presented for headache and altered mental status. Four days prior, he underwent endoscopic sinus surgery for nasal polyps. Over the two previous days, he gradually developed a headache and was brought to the emergency department when his wife noted mild confusion and generalised weakness. His examination was notable for a heart rate of 101 beats per minute, clear nasal discharge, meningismus and confusion to the date with generalised weakness. A lumbar puncture revealed cloudy cerebrospinal fluid (CSF) with a white blood cell count of 3519x10ˆ9/L (95% neutrophils). A CT scan of the head was obtained (figure 1).

Figure 1

Non-contrast CT scan of the head in axial plane.

What is the appropriate next step in management?

  1. Obtain MRI of the brain to localise ischaemic damage.

  2. Administer broad-spectrum antibiotics, including pseudomonal coverage.

  3. Consult otolaryngology to arrange functional endoscopic sinus surgery for CSF leak closure.

  4. Consult neurosurgery for surgical decompression of mass lesion(s).

  • CT/MRI
  • infectious diseases
  • bacterial
  • neurology
  • headache
  • ENT
  • head

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  • Handling editor Ellen J Weber

  • Contributors CKP and PSJ contributed equally.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; internally peer reviewed.