Case Report Insights: A Rapidly Enlarging Headache

Case Report Insights are in-depth interviews that take you inside the diagnosis with clinicians who recently published a Consultant case report.

In this Consultant Case Report Insights, Evan M. Masutani, MD, PhD; Mariam Fahim, DO; and Peter Wei, DO, discuss their study, “A Rapidly Enlarging Headache,” which features a 6-year-old boy with recurrent otitis media who presented with subacute, new-onset headache and photophobia. To read the full What's Your Diagnosis? article, visit: https://www.consultant360.com/whats-your-diagnosis/rapidly-enlarging-headache

Transcript

Evan M. Masutani, MD, PhD: Hi, my name is Evan Masutani. I'm a resident physician in diagnostic radiology at the University of California, San Diego.

Mariam Fahim, DO: I'm Dr. Fahim. I'm the program director here at UHS transitional year. I am a pediatrician. I graduated from the Loma Linda pediatric residency, previously at the Arizona College of Osteopathic Medicine, and have also been an associate professor at Western University of Health Sciences.

Peter Wei, DO: I'm Dr. Wei. I'm a family medicine physician. I did my medical school at Western University Health Sciences, and I did my family medicine residency at UHS Southwest MEC. I saw this patient when I was a PGY2 resident, before I actually graduated, in the emergency room.

Consultant360: Could you give us an overview of the case?

Masutani: This case is regarding a six-year-old male with a fairly unremarkable past medical history. Just some recurrent ear infections, otitis media, and then he subsequently presented to Dr. Fahim's clinic for six days of new onset, new onset headache, and some photophobia. He characterized it as occurring more in the late morning, but it didn't really wake him up from sleep. He did experience some vomiting and some photophobia, but not much else. Fairly nonspecific presentation otherwise.

He had previously presented to the urgent care and had tested negative for SARS-COVID-19 and influenza and was taking Tylenol and ibuprofen for pain relief. Because of the nonspecific symptoms and signs, a tentative diagnosis of nausea and migraines was made, and the patient was instructed to follow up. However, due to worsening severity of the headaches, the patient subsequently presented to the emergency department, up in the adjacent emergency department facility.

Subsequently, they did take a non-contrast head CT. Again, fairly non-specific findings, except for some asymmetric opacification of the right maxillary sinus. So, possibly a brewing sinus infection, and he was discharged with ondansetron and told to follow up with an outpatient again. However, within 24 hours, the patient’s symptoms, headache, continued to get worse, and notably, he started to develop this peculiar sort of frontal scalp swelling and presented to the same emergency department. Thereafter, they did a repeat CT where they did find opacification of the anterior right ethmoid air cells, as well as the right frontal ethmoidal recess.

We also noted the involvement of the forehead as well with this growing infection. This is when Dr. Wei saw him in the emergency department. He immediately began the patient on IV antibiotics, on unison, and was subsequently set up expediently to go to the regional tertiary care inpatient pediatric hospital. Then once he was sent there, he subsequently underwent magnetic resonance imaging of the of the head and orbits, where the diagnosis of Pott’s puffy tumor was confirmed.

He was then taken under the care of photolaryngology. They conducted endoscopic sinus surgery, where they drained the fluid collections, and also did some aspiration of the scalpel lesion. And then he was initially on ceftriaxone and vancomycin. These cultures did grow Streptococcus intermedius. He was de-escalated to clindamycin, I believe, and discharged as an outpatient.

He was inpatient for almost a week and has since been following up regularly with his outpatient pediatrician. The last time I saw him, which was a number of months, if not years, after his discharge, he was doing quite well. No repeat or reproduction of these symptoms, and that's kind of where we are today.

Consultant360: What aspects of the case challenged or reinforced your initial clinical assumptions?

Fahim: I think a big part of it is that the initial presentation was very benign, as in headaches. It could be sinus, but we never thought of Pott’s puffy tumors, especially because it's not that common in that age group, that young. So, it was kind of like we kept treating other things. We kept reading, you know, headaches, we kept treating sinusitis, but we didn't think of Pott’s puffy tumor until, of course, things got worse.

We had the mass growing. Then that's when Dr. Peter Wei kind of saw that at the ER, and we're like, oh, maybe it is Pott’s puffy tumor.

Consultant360: How did you initially approach this case, and did that approach change over time?

Fahim: I always think that, and I always tell my residents, if your initial diagnosis is not improving with your treatment, then rethink your diagnosis. So the initial diagnosis was sinusitis and headache, and we treated it. However,  things kept getting worse and worse, and the headache kept getting, you know, not remitting and going to the ER. So that's when we had to think outside the box. It’s not just a migraine, you know, maybe there is more to it. But, again, what gave it away was the growth on the forehead.

Consultant360: Can you describe the moment when you realized you had the correct diagnosis?

Wei: Yeah, I think definitely when the patient came into the ED, when I saw the patient. Because I worked at Dr. Fahim's clinic before, I kind of knew a little bit about the patient, and when I saw them, when the mask came up, it definitely was not normal. So that definitely prompted us to kind of take a different angle.

Then on top of that, it just didn't look right. The kid basically had a lot of photophobia. His headache wasn't like the normal headache you would get with migraines. Like the way he described it, he kind of said that it felt like his head was exploding, especially in the frontal area where that mass was.

So I think kids are very honest with their answers and how they can explain the pain. It just didn't sound like a typical migraine that you normally hear from children. Given his age, at the time, and being male, you know, as we know, that males don't get migraines as often, it just kind of prompted us to kind of take a different angle and look at it from a different perspective. Instead of migraine, it's more like Pott’s puffy tumor.

Consultant360: What key datapoint confirmed the diagnosis?

Wei: I think for me, definitely the CT imaging, showing that there is this abnormal growth, and finding it on the CT. That was really what prompted me to admit the patient. I would say that's the main point. Also, the patient had a mild white blood cell count that definitely, you know, further supported that it was just not a migraine. It was more, something more severe. He had an infection going on. So I think the lab results from like the CBC and the imaging from the head CT really helped us confirm the diagnosis.

Fahim: Yeah, I agree. The frontal sinus was examined using contrast CT, and even in our article, we point out that a 0.4-0.5 centimeter thickness, which is beyond the bones, beyond the frontal bone, really made it come to reality for us.

Masutani: Just to add to that, the patient was seen back-to-back at the ED, basically. On the first ED presentation, there was no frontal scalp swelling, and so, within 24 hours, the sudden emergence of this frontal scalp mass really did seem quite unusual.

Consultant360: What did you learn from this case, and what should other clinicians take away from it?

Wei: I think for me, it would just be a reminder that always kind of keep your differentials open. What are all the possibilities that can happen? It's very easy to think that it's always just sinusitis or rhinitis or an allergic reaction, or even migraines. Just having those differentials open, always thinking about what the possible worst-case scenario is, and rolling them out, I think, would help ensure that patient care is improved and that these conditions are figured out earlier to help the patient.

Fahim: Yeah, I agree. I also think of the bad and the evil, like, yeah, every day we see sinusitis or migraines. However, when we treat, and things aren't going the way they should, we have to broaden our differential diagnosis and consider what's out there that's unusual. Then it can, you know, progress very fast if we don't pick up on it. So it's very crucial that it's detected early and it's not spread throughout. Think always outside the box.

Masutani: I agree with all that. I think the other thing that was really critical in this case, too, was just sort of the teamwork that everybody had with both the care team as well as with the family. I had the privilege of meeting the family in clinic when I was a resident, and they're wonderful people. The fact that they listened to the return precautions and did bring back their child when they noticed something was wrong within 24 hours, I really think that's what kept this brewing infection from sort of spiraling out of control. It was a big relief looking at the imaging when they didn't see any sign of any sort of epidural abscess or anything more central that would have led to a much worse outcome. I think having a good rapport and good teamwork with the families, especially when dealing with children, is such a big part of patient care.

This transcript was edited for clarity. 

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