You are here

Article Text

Article menu
Download PDFPDF
Image challenge
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}partners.org

Abstract

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
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

https://doi.org/10.1136/emermed-2020-210071

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    View Full Text

    Footnotes

    • 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.