University of Missouri Hospital and Clinics Columbia, Missouri
Introduction: Headaches and neck pain are common patient complaints in a family medicine clinic, potentially accounting for up to five percent of patient concerns1. Typically, these chief complaints are passed off as migraines, tension headaches, stress, or tight musculature in the neck and shoulders. Although most of the headaches are classified as benign, 4% do have other more emergent pathology involved2.
Case Study: An 18-year-old male with a history of type 1 diabetes presented to a primary care office for headaches, neck pain, and a low-grade fever. This atypical appearing headache and neck pain alarmed his primary care physician. Upon presentation to the ED he was febrile to 38.2oC. Laboratory testing showed slight leukocytosis and elevated ESR /CRP. He initially had some pain with neck flexion but resolved with Toradol, Compazine, and fluids. He was diagnosed with a migraine as his symptoms had resolved. Sixteen hours later he returned to the ED as his headache was worse with uncontrolled vomiting. He again was febrile to 39oC and was unable to flex his neck. This became concerning for meningitis or other infectious etiologies. A CT was obtained first to evaluate for increase intracranial pressure before a lumbar puncture was considered. CT of his head showed moderate-sized mass within the right parietal lobe with midline shift. He was admitted to the neurosurgical ICU and underwent biopsy of the mass which was consistent with an abscess. Cultures were taken which grew Eikenella corrodens, Streptococcus intermedius, and Prevotella species. The patient was placed on broad spectrum antibiotics which were deescalated after 3 days to ceftriaxone and metronidazole for which he remained on for 12 weeks. He was able to discharge from the hospital 9 days after his diagnosis.
Discussion: This case illustrates that every complaint of a headache that comes to primary care should be evaluated for concerning/atypical symptoms. Most times these are the more common tension headaches, migraines, or tight paraspinal musculature, but 4% of the time there is intracranial pathology. This patient had some signs of atypical headaches with his fevers, nausea, and pain with neck flexion. Though OMT can be beneficial for most headache complaints, this patient would have had contraindications with his symptoms and then increased intracranial pressure on head imaging. When a patient walks into a family medicine clinic with a headache and fever, think about alternative diagnosis as maybe it is one of the few cases with intracranial pathology.
