Episode 337 – Spaced Learning Series – New Headache
May 31, 2024
auto_awesome
Mukund, Jasdeep, and Valeria discuss a complex case of a pregnant woman with a new headache. They cover topics like secondary headaches, CSF lymphocytic pleocytosis, differentials for headaches in pregnancy, neurological complications, and diagnostic evaluation of viral encephalitis.
Different headache patterns in pregnant women may signal secondary causes like varicella-zoster virus encephalitis.
Anatomical approach helps in distinguishing primary and secondary headaches, with red flags guiding clinical suspicion for secondary causes.
Recognition of signs like elevated intracranial pressure and abnormal CSF findings is crucial in diagnosing and managing viral encephalitis cases.
Deep dives
Patient Presentation and History
A 33-year-old pregnant woman presents with a four-day history of a different headache pattern from her usual migraines. She experiences whole cephalic throbbing headaches worsened with physical activities and not relieved by usual medications. The absence of typical migraine symptoms raises concern for alternative causes.
Approach to Headache and Secondary Causes
Distinguishing primary and secondary headaches, the speaker emphasizes an anatomical approach to secondary headaches categorizing them into intracranial, head and neck, and systemic causes. Red flags for secondary causes, such as sudden onset in older patients, history of cancer, or neurological signs, are highlighted to guide clinical suspicion.
Neurological Examination and Differential Diagnosis
The neurological exam reveals signs of elevated intracranial pressure with increased tone in all extremities and upper motor neuron lesion. Potential differential diagnoses include conditions like intracranial tumor, hydrocephalus, idiopathic intracranial hypertension, and venous sinus thrombosis.
Diagnostic Evaluation and Final Diagnosis
Laboratory findings show elevated C-reactive protein, and CSF analysis indicates lymphocytic pleocytosis with high protein levels. CSF PCR confirms varicella-zoster virus. Imaging rules out superagnative hemorrhage and thrombosis. Treatment includes intravenous acyclovir for viral encephalitis.
Management Decisions and Follow-up
Empiric antimicrobial therapy was initiated, including IV antibiotics, and steroids were considered based on the patient's presentation. Detailed discussion on the management of herpes encephalitis included the importance of PCR testing, treatment with acyclovir, and potential use of steroids in cases of inflammation.
Summary and Teaching Points
The case highlights the clinical presentation, differential diagnosis, diagnostic challenges, and treatment considerations for a pregnant patient with varicella-zoster virus encephalitis. Teaching points include peculiar manifestations of the disease, use of CSF analysis and PCR for diagnosis, and considerations for antiviral therapy and steroids in viral encephalitis.
