Ete was a five-year-old boy. At 2:00 in the morning, he woke up screaming with pain from a headache. Mom gave him Tylenol but he was not able to go back to sleep. By the time I saw him, he had suffered with headache for almost twenty-four hours. His vital signs were normal and he had no other complaints or recent illnesses, but Ete looked miserable, holding the top of his head with tears in his eyes.
In adults, sudden on-set headaches like this may be caused by a subarachnoid hemorrhage. This is a very serious condition caused by the rupture of an abnormal blood vessel, usually an aneurysm, at the base of the brain. If the aneurysm is not discovered and treated, complications can lead to brain damage or death.
The work-up for adult patients with this kind of headache is very straightforward. A CT scan of the head shows brain hemorrhage in about ninety percent of people who have one. If the CT is normal, we recommend a lumbar puncture to make sure there is no blood in the fluid that bathes the brain and spinal cord.
All of that is for adult patients. I had never heard of a child having a subarachnoid hemorrhage. Still, Ete’s story was so unusual and worrisome I had to pursue it as a possible diagnosis.
It’s important for emergency physicians to consider the potential risks involved in the diagnosis and treatment of patients. A CT scan of Ete’s head could show a subarachnoid hemorrhage. However, I was not comfortable doing a CT on a five year old. Radiation has bad effects that accumulate over time. So, in little kids, we use CT only if there is no other option.
I ordered morphine and called our pediatrician who agreed to admit Ete to the hospital. He was feeling better by the time he went upstairs.
The first time nurses in the Pediatric Unit checked his vital signs; he had a temperature of 103. This was a sudden change, as he had not had a fever at home or in the emergency department. The pediatricians did a lumbar puncture right away. The results showed he had meningitis.
Ete is a great example of how patients forget to read the book before they come to the emergency department. Though I thought of meningitis as a possible reason for his headache, I was sure he didn’t have it because he had none of the other typical symptoms. All this made for a very interesting and challenging case. Fortunately, Ete should do fine.
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