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CPC Anthony Catapano, DO EM Clerkship Director St. Joseph’s Regional Medical Center Paterson, NJ

CPC Anthony Catapano, DO EM Clerkship Director St. Joseph’s Regional Medical Center Paterson, NJ October 12, 2014. Welcome to Caesar’s Palace. “This isn’t the Real Caesar’s Palace, is it?”. “What do you mean?”. “Um, did Caesar live here?”. “Vegas, baby. Vegas!”.

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CPC Anthony Catapano, DO EM Clerkship Director St. Joseph’s Regional Medical Center Paterson, NJ

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  1. CPC Anthony Catapano, DO EM Clerkship Director St. Joseph’s Regional Medical Center Paterson, NJ October 12, 2014

  2. Welcome to Caesar’s Palace

  3. “This isn’t the Real Caesar’s Palace, is it?” “What do you mean?” “Um, did Caesar live here?”

  4. “Vegas, baby. Vegas!” Trent: “We got to get you out of Dodge. We’re going to Vegas tonight.” Mike: “What are you talking about?” Trent: “Vegas. Las Vegas!” Mike: “What are you talking about? When are we going to Vegas?” Trent: “We’re going tonight. You bring something nice to wear.” Mike: “I’m not going to Vegas!”

  5. “Alright, listen. I took out $300…” “…but I’m only betting with $100.”

  6. I Also Think about Foreheads

  7. The Case – Chief Complaint • 19 year old with forehead swelling for two weeks

  8. What I Know from the HPI • Complains of occasional headaches • Occasional fevers • No neurological symptoms, no vision changes • Treated at multiple institutions for sinusitis • Sinus pressure, nasal discharge, nasal congestion • Several courses of antibiotics – including Levaquin

  9. What I Don’t Know from the HPI • What other antibiotics were taken? • Recent travel around the states • Any travel outside the US? • Student. Exchange student? • Immunizations up-to-date? • Cancer history in mother • Pertinent? What kind?

  10. What I know from the Exam • VS: BP: 113/71, HR: 81, RR:16, O2: 97% RA, T: 97.6 F • PE: • HEENT: 6 cm X 10 cm boggy swelling with fluctuance and tenderness present on the forehead. • No erythema present, no warmth • Throat: No exudates, but yellow drainage on posterior pharynx • Neuro: Normal

  11. Labs • CBC: Normal WBC: 9 Hgb: 14.2 Hct: 41.5 Plt: 242 Diff: N: 71, L: 19, M: 7 • SMA-7: Normal • Na: 142 • K: 3.6 • Cl: 104 • HCO3: 31 • BUN: 13 • Cr: 1.08 • Glu: 84 • ESR: 37 • Slight Elevation (0-10) • Non-specific

  12. CT

  13. CT

  14. CT

  15. “Please Clinically Correlate” Sincerely, your favorite radiologist/neuroradiologist

  16. Differential Diagnosis • Hematology-Oncology • Lymphoma • Langerhan Cell Histiocytosis • Dermoid cyst • Infectious • Tuberculosis • Fungal • Aspergillus • Mucormycosis • ENT • Frontal Sinus Mucocele • Pott’s Puffy Tumor • Trauma • Hematoma • Skull fracture • Leptomeningeal Cyst • Recent craniotomy/sinus surgery • Dermatology • Abscess/MRSA • Sebaceous Cyst/infected sebaceous cyst • Lipoma • Rheumatologic • Granulomatosis with Polyangiitis (Wegener’s Granulomatosis)

  17. Trauma • Hematoma • Skull fracture • Leptomeningeal Cyst • Recent craniotomy/sinus surgery • Not Mentioned in HPI

  18. Dermatology • Abscess/MRSA • Sebaceous cyst/infected sebaceous cyst • Lipoma

  19. Rheumatologic • Granulomatosis with Polyangiitis (Wegener’s Granulomatosis)

  20. Hematology-Oncology • Lymphoma • B cell • T cell • NHL • Langerhan Cell Histiocytosis • Dermoid Cyst

  21. Infectious • Tuberculosis • Fungal • Aspergillus • Mucormycosis

  22. ENT • Frontal Sinus Mucocele • Pott’s Puffy Tumor

  23. Remaining Differentials • Abscess/MRSA • Tuberculosis • Fungal • Aspergillus • Frontal Sinus Mucocele • Pott’s Puffy Tumor

  24. CT Abscess Epidural Abscess • With IV contrast

  25. CT • With IV contrast

  26. Abscess Frontal Sinus Erosion Epidural Abscess Opacification of Right Frontal Sinus

  27. Abscess Frontal Lobe edema Stranding Frontal Sinus Erosion

  28. Epidural Abscess Abscess Epidural Abscess

  29. Remaining Differentials • Abscess/MRSA • Tuberculosis • Fungal • Aspergillus • Frontal Sinus Mucocele • Pott’s Puffy Tumor

  30. Wish List • CRP • Rapid HIV • PPD, AFB, CXR • MRI Brain • Biopsy

  31. Pott’s Puffy Tumor • 1st described by Sir Percivall Pott – 1869 • Subperiosteal abscess and osteomyelitis • M/C: frontal sinuses • Non-neoplastic complication of sinusitis • Forehead swelling • Typically in adolescents

  32. Pott’s Puffy Tumor • Rare • Era of Antibiotic therapy • Typically delayed diagnosis

  33. Pathology • Untreated/Improperly treated sinusitis • Chronic sinusitis • Typically bacterial • Polymicrobial, Strep, Staph, anaerobes • Rare: H. influenzae, Proteus, Fusobacterium, Pseudomonas, Bacteroides, Pasteurella multocida

  34. Possible Etiologies • In our case, maybe improperly/partially treated • Intracranial epidural abscess • MRSA • Multiple antibiotics • Fungal • Immunocompromised, diabetic, toxic • TB • Traveling, exchange student? Living in college dorms/close quarters? • Non-immunized patient? H. influenzae?

  35. Complications • Typically delayed diagnosis • Favors development of complications, which are frequent • 60-100% of patients develop intracranial complications • Intracranial extension • epidural abscess, subdural empyema, intracerebral abscess, cavernous sinus thrombosis, meningitis, cerebritis, seizures, focal neurological deficits, AMS, preseptal cellulitis, orbital cellulitis

  36. Pott’s Puffy Tumor with epidural abscess

  37. Treatment • Treatment: • Admission • Broad spectrum IV abx • Consult: Neurosurgery, ENT, ID • Surgical debridement • Gram Stain, Culture, aerobic/anaerobic, AFB, Fungal • MRI • PICC line for long-term parenteral antibiotics after discharge

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