A 5-year-old girl is brought to the emergency department after having a seizure at home. Approximately an hour ago, the patient collapsed at the dinner table and developed full body shaking and urinary incontinence. Her mother says that the girl has had a mild headache and fatigue for the past few days. On examination, the patient is sleepy and difficult to rouse. Vital signs are normal. Cardiopulmonary examination is unremarkable. CT scan of the head is shown in the image below: Which of the following historical details is most relevant in establishing this patient's diagnosis?

Question

A 5-year-old girl is brought to the emergency department after having a seizure at home.  Approximately an hour ago, the patient collapsed at the dinner table and developed full body shaking and urinary incontinence.  Her mother says that the girl has had a mild headache and fatigue for the past few days.  On examination, the patient is sleepy and difficult to rouse.  Vital signs are normal.  Cardiopulmonary examination is unremarkable.  CT scan of the head is shown in the image below:  Which of the following historical details is most relevant in establishing this patient's diagnosis?

Quizplus · Accepted Answer

11ec160b_3aac_b160_9249_d562135e1c7d_MD0001_00 This patient's head imaging reveals a ring-enhancing lesion with surrounding edema, findings concerning for a brain abscess. Presentation of a brain abscess is often nonspecific and can include headache with or without fever or focal neurologic deficits. Seizure may also be the initial manifestation in some patients, as seen in this girl. A brain abscess can be due to the hematogenous spread of bacteria from a distant location (eg, pulmonary infection with bacteremia) or the direct extension of a head and neck space infection, such as otitis media, sinusitis, or mastoiditis. Because of its anatomic proximity to the middle ear, a temporal lobe abscess, as seen in this patient, can develop as a rare complication of acute otitis media; a recent history of fever, ear pain, and bulging tympanic membrane in this patient would support this diagnosis. Microbiologic examination of the abscess generally reflects the primary site of infection, such as Streptococcus pneumoniae from middle ear infections. (Choice A) The risk of certain epilepsy syndromes (eg, absence seizures, juvenile myoclonic epilepsy) is increased with a positive family history. This patient's seizure was provoked by a focal intraparenchymal lesion, which is inconsistent with epilepsy. (Choice B) Shigella infection classically causes fever and bloody diarrhea and can be associated with seizure and encephalopathy, particularly in children. However, brain abscesses are not associated with this infection. (Choice C) Congenital toxoplasmosis can cause long-term neurologic sequelae (eg, seizures, hearing loss), but imaging typically reveals intracranial calcifications, which are not seen here. In addition, although multiple ring-enhancing lesions are classic for CNS toxoplasmosis in immunocompromised adults, these are not typically present in patients with congenital infection. Moreover, this patient has a single lesion. (Choice D) Immune thrombocytopenia can cause petechiae/bruising, recurrent minor bleeding (eg, gingival bleeding), or severe hemorrhage (eg, gastrointestinal, intracranial). Seizure may be a presenting sign of an acute intracranial bleed, but CT scan typically reveals a hyperdense fluid collection, not a ring-enhancing lesion. Educational objective: A brain abscess appears as a ring-enhancing lesion on imaging and typically causes headache with or without fever and neurologic symptoms (eg, seizure). Pathogenesis often involves direct spread from head and neck space infections, such as acute otitis media. __________ References: Brain abscess. (http://www.ncbi.nlm.nih.gov/pubmed/28722871) Acute otitis media and associated complications in United States emergency departments. (http://www.ncbi.nlm.nih.gov/pubmed/30113560) Otogenic brain abscesses: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/30062135)

A 5-Year-Old Girl Is Brought to the Emergency Department After