Grand case report

Secondary Headache
By:
Mutia Dewi Assifa

Supervisor:
dr. Riki Sukiandra, Sp.S

CLINICAL CLERKSHIP DEPARTMENT OF NEUROLOGY

RSUD ARIFIN ACHMAD
FACULTY OF MEDICINE UNIVERSITY OF RIAU
PEKANBARU
2020
PATIENT’S IDENTITY
Name Mrs. U
Age 47 years old
Gender Female
Address Siak

Religion Islam
Marital status Married
Occupation Housewife
Date of hospital admission December, 30th 2019
Medical record 0132xxx
Chief complaint

Headache since two weeks before

admitted to the hospital
Present illness history
2 weeks before admission
Headache, comes in sudden
and felt more worsening, give
any impact on her daily
activity. Patient didn’t
consume any drugs for her
complain. It following by
fever, nausea, and vomit. She
vomitting 4 times a day but
did not spurting out. She also
experienced numbness on her
lower extremity.
2 days before admission
Patient was seizure, happen 3
times a day in whole body.
When the seizure was
happened, the patient was
stiffen, in this phase she was
lost her conciusness. Then
following by jerk and twitch
ritmically and regaining
conciousness slowly. Once it
happened in 3-5 minutes.
According to the report of
emergency room. The patient
was in apatis condition.
Past illness history

HIV-seropositive since April 2019.

Initiated ART since April 2019 ago but dropped out in the last 4
months because she has consuming Anti-Tuberkulosis
treatment.

TB infection since Agustus 2019 and has iniated by

antituberculosis treatment
Socioeconomic history
• The patient is currently a housewife, but 5 years ago worked as
a household assistant.

Family disease history

Second husband : HIV-seropositive and had passed

away in 2011 due to opportunistic infections.

Children : not infected.

RESUME
• Mrs. U, 47 years old was admitted to the hospital with
headache since 2 weeks before. The complain was
following by a high fever, seizure, nausea, vomit, and
also numbness on her right lower extremity and
difficulties when walking. She didn’t consume any drugs
for her complaint. The patient has been diagnosed with
HIV infection in April 2019 and has initiated ART but
dropped out in August 2019. Her second husband also
infected by HIV.
Generalized condition
BP 104/60 mmHg
Pulse 80 bpm, regular
RR 20 tps, thoracoabdominal
T 37,00C
Weight/Height/BMI 55 kg/155 cm/22,9 kg/m2 (normoweight)
Eyes Pale conjunctiva (-/-), mid-position fixed pupil
Cardiovascular HR 140 bpm, regular, murmur (-), gallop (-)
Respiratory Vesicular (+/+), rhonchi (+/+), wheezing (-/-)
Abdomen Normal skin turgor, bowel sounds 8 tps
Lymph nodes Swollen lymph nodes (-)
Neurological status

Composmentis Cooperative
Consciousness
(E4V5M6)
Cognitive
Normal
function
Nuchal rigidity Negative
Cranial nerves - Olfactory
  Right Left Interpretation

Sense of smell Normal Normal Normal

Cranial nerves - Optic

  Right Left Interpretation
Visual acuity
Visual fields Normal Normal Normal
Colour recognition
Cranial nerves - Occulomotor
Right Left Result
Ptosis (-) (-)
Pupil    
Shape Round Round
Size 3 mm 3 mm

Pupillary reflex     Normal

Direct (-) (-)
Indirect (-) (-)
Cranial nerves - Trochlear
  Right Left Interpretation

Extraocular
Movement (+) (+) Normal

Cranial nerves - Trigeminal

  Right Left Interpretation

Motoric
Sensory Normal Normal Normal
Corneal reflex
Cranial nerves - Abducens

  Right Left Interpretation

Eyes movement Normal Normal

Normal
Strabismus (-) (-)
Corneal Refleks (-) (-)
Cranial nerves - Facial

Interpretatio
Right Left
n
- Tic motor (-) (-)
- Frowning Normal Normal
- Raised eye brow Normal Normal
- Close eyes Normal Normal 
Normal  
- Corners of the Normal
mouth   Normal
- Nasolabial fold Normal Normal  
- Sense of taste Normal Normal
- Chovstek Sign (-) (-)
Cranial nerves - Vestibulocochlear
  Right Left Interpretation
Normal Normal Normal
Hearing sense

Cranial nerves - Glossopharyngeal

  Right Left Interpretation

Arcus faring Normal Normal

Normal
Flavor sense Normal Normal
Gag reflex (+) (+)
Cranial nerves - Vagus
  Right Left Interpretation

Arcus pharyng Normal Normal Normal

Dysphonia (-) (-)

Cranial nerves - Accessory

  Right Left Interpretation

Motoric Normal
Trophy Normal Eutroph Normal
Eutrophy
y
Cranial nerves - Hypoglossal
  Right Left Interpretatio
n
Motoric Normal Normal
Trophy Eutrophy Eutrophy
Tremor (-) (-)
Dysarthria (-) (-) Normal
Sensory   Right Left
Interpretat
ion

Touch Normal Normal

Pain Normal Normal
Temperature Normal Normal

Proprioceptive
 Position
 Two point Normal Normal Normal   
discriminat Normal Normal
ion
 Stereognosi Normal
Normal
s
Normal Normal
 Graphestesi
a Normal Normal
 Vibration
Motoric
  Right Left Interpretation

Upper Extremity    
Strength (distal, medial, proximal) 5,5,5 5,5,5
Tone Normal Normal
Trophy Eutrophy Eutrophy
Involuntary movements (-) (-)
Clonus (-) (-)

Lower Extremity Normal

Strength (distal, medial, proximal)  5,5,5  5,5,5
Tone Normal Normal
Trophy Eutrophy Eutrophy
Involuntary movements (-) (-)
Clonus (-) (-)

Body    
 
Trophy Eutrophy Eutrophy
Normal
Involuntary movements (-) (-)
Reflexes
  Right Left Interpretation
Physiologic    
Biseps (+) (+) Physiologic
Triseps (+) (+) reflex (+)
Patella (+) (+)  
Achilles (+) (+)

     
Pathologic
(-) (-)  
Babinsky
(-) (-)  
Chaddock
(-) (-) Pathologic reflex
Hoffman-Tromer
(-) (-) (-)
Oppenheim
(-) (-)  
Schaefer
     
Coordination
  Right Left Interpretation
Point to point movement
 
Walk heel to toe
Difficult Difficult Not testable
Gait
to assess to assess  
Tandem
 
Romberg

Autonom
• Urination : Urine catheterization is installed
• Defecation : Normal
Other examination
Laseque Unlimited (>70)
Kernig’s Unlimited (>130)
Patrick (-/-)
Contrapatrick (-/-)

Valsava test -
Brudzinski -
RESUME
• Composmentis Cooperative (E4V5M6)
• Generealized condition was in normal limit
• Neurological status was in normal limit
• Sensory and motoric examination was in normal limit
• Reflexes, autonom and other examination was in normal limit
• Coordination was difficult to access
WORKING DIAGNOSIS
Clinical : Secondary Headache + Symptomatic Epilepsy + Hemiparastesia
Dextra

Topical : Cerebri Hemisphere Sinistra

Etiological : SOL et causa susp. Cerebral Abcess

DD : Cerebral Toxoplasmosis

Secondary : HIV-seropositive, TB on OAT

Suggestive examinations
• Blood routine test
• Blood chemistry test
• Electrolyte
• Serum IgG anti-toxoplasma and IgG avidity
• Head CT-Scan with contrast
• Thoracic X-Ray
• Funduscopy
• EEG
MANAGEMENT
• O2 3 lpm
• IVFD RL 20 dpm
• Cotrimoxazole 1x960 mg tab
• Ketorolac 3x30 mg IV
• Ondansentron 1x 8mg/4ml IV
• Omeprazole 1x40 mg IV
• Phenytoin 3x100 mg IV
• Dexametason 4x4 mg IV
• Paracetamol 3 x 500 mg tab
LAB FINDINGS
Blood Chemistry (Dec,28th
2019)
• Creatinin : 0,70 mg/dl 3.
Blood Routine (Dec, 28th
2019)
Elektrolyte
• Hemoglobin :11,0 gr/dl
• Na+ : 142 mmol/L
Hematocrit : 32,2%
• K+ : 3,0 mmol/L
Leucocytes : 10.900
• Cl- : 104 mmol/L
/mm3
• Platelets : 371.000/mm3
Imunology and serology
• CD4 : 185 sel/ul
• CD4% : 10,95%
Head CT Scan (no contrast)
Interpretation :
- There is no pathologic hypodense or
hyperdense lesion in the brain parenchyma
- Sulci, gyrus and fissura sylvii are not
prominent
- The boundaries of the white matter and gray
matter
- The ventricular system and cysterna do not
narrowed or widened
- Midline shift (-)
- The cerebellum and brainstem are normal
- There is no SOL
- Paranasal sinuses and mastoidal air visualized
normodens

Conclusion : there is no abnormality in this CT

Scan without contrast.

Suggestion : CT Scan with contrast. .

FINAL DIAGNOSIS

Secondary Headache+ simptomatic

epilepsi ec SOL susp. Cereberal
Abcess +TB on OAT+HIV infection.
Follow up
Jan 1, 2020

• Nausea
• Vomit Assessment • Metoklorpramid
• GCS : E4V5M6
• Blood pressure : 139/89 mmHg and curcuma was
• Pulse : 150 bpm, reguler • Secondary added to the
• Respiratory rate : 20 times per minute therapy list
• Temperature : 37,2 celcius headache+seizure+
Subjective hemiparastesia dextra +
TB on OAT + HIV Plan
& Objective
infection
Follow up
Jan 2, 2020

Assessment
• Seizure 1 times.
• Nausea,
• Use NGT
• Vomit • Consult to
• GCS : E4V5M6 • Secondary
pulmonologist
• Blood pressure : 120/70 mmHg
• Pulse : 80 bpm, reguler
headache+seizure+
• Respiratory rate : 20 times per hemiparastesia
minute
• Temperature : 37,7 celcius
dextra + TB on
OAT + HIV
Subjective & infection Plan
Objective
Follow up
Jan 3, 2020

Assessment
• Seizure 1 times.
• Nausea,
• Vomit
• Secondary • Use NGT
• GCS : E4V5M6
• Blood pressure : 120/70 mmHg headache+seizure+ • Waiting answer
• Pulse : 80 bpm, reguler
• Respiratory rate : 20 times per hemiparastesia from pulmonologist
minute
• Temperature : 37,7 celcius
dextra + TB on
OAT + HIV
Subjective & infection Plan
Objective
Follow up
Jan 4, 2020

Assessment
• Seizure 1 times.
• Nausea,
• Vomit
• Secondary • Use NGT
• GCS : E4V5M6
• Blood pressure : 120/70 mmHg headache+seizure+ • Waiting answer
• Pulse : 80 bpm, reguler
• Respiratory rate : 20 times per hemiparastesia from pulmonologist
minute
• Temperature : 37,7 celcius
dextra + TB on
OAT + HIV
Subjective & infection Plan
Objective
Follow up
Jan 5, 2020

Assessment
• Seizure 1 times.
• Nausea,
• Vomit
• Secondary • Use NGT
• GCS : E4V5M6
• Blood pressure : 120/70 mmHg headache+seizure+ • Waiting answer
• Pulse : 80 bpm, reguler
• Respiratory rate : 20 times per hemiparastesia from pulmonologist
minute
• Temperature : 37,7 celcius
dextra + TB on
OAT + HIV
Subjective & infection Plan
Objective
LITERATURE REVIEW
HEADACHE

• Headache is pain or discomfort on whole

area of the head.
• Headache disorders are divided
intoprimary headache syndromes (in which
the headache and associated features
comprise the disorder itself) and secondary
headache syndromes (in which the
headache results of another etiologies).
Classification based on causes
Primary Headache
• Periodic disorder with unilateral or bilateral headache
and can be following with vomiting and visual
Migraine disturbances.
• There is family history of migraines on commonly
patient.
• Unknown etiology contraction of the head and neck
Tension muscles is a mechanism causes pain.
• Triggered by psychogenic factors such as anxiety or
type depression or by local disease on head and neck.
• Headache starts from the blunt pain in various places until a
Headache thorough pressure sensation to the feeling of the tight-
tied/tense.
• Unilateral headache, red eye
Cluster • Feel pain around the eye for 20-120 minutes, can be
repeated in several times a day
Headache • Happen on night
• Triggered by Alkohol, cigarettes
Secondary Headache

• Headache attributed to head and/or neck trauma and cranial or cervical

vascular disorder
• Headache attributed to non-vascular intracranial disorder
• Headache attributed to a substance or its withdrawal and infection
• Headache attributed to disorder of homeoeostasis
• Headache or facial pain attributed to disorder of cranium, neck, eyes, ears,
nose, sinuses, teeth,mouth, or other facial or cranial structures.
• Headache attributed to psychiatric disorder
• Cranial neuralgias and facial pains
• Cranial neuralgias and central causes of facial pain
• Other headache, cranial neuralgia central, or primary facial pain.
EPILEPSY

• Epilepsy is defined as a condition of recurrent

unprovoked seizures in 24 hours.
• The discharge may result in an almost instantaneous loss
of consciousness, alteration of perception or impairment
of psychic function, convulsive movements, disturbance
of sensation, or some combination thereof.
Classification
Treatment
SPACE OCCUPYING LESION (SOL)
• SOL is a extended lesion in brainsincluding tumor, hematoma
and abscesses.
• Because the cranium is stiff with a fixed volume,then the
lesions will increase the intracranial pressure.
• A lesion that extends first will be accommodated by removing
the cerebrospinal fluid from the cavity of the cranium.
Eventually venous will compression and disorders
braincirculation and cerebrospinal fluid will appears, so the
intracranial pressure will increase.
CEREBRAL ABSCESS

• Cerebral abscess is defined as a focal infection within

the brain parenchyma, which starts as a localized area of
cerebritis, which is subsequently converted into a
collection of pus within a well-vascularized capsule.
• It is a dynamic focal form of intracranial suppuration
and a serious life-threatening emergency.
Stages
Cerebral Abscess with HIV-infected
patient

• Central nervous system disorders associated with HIV infection

occur most commonly at an advanced stage of
immunosuppression.
• The most frequent cause of neurological disease in HIV patients is
an infectious agent, principally Toxoplasma gondii, Cryptococcus
neoformans and Mycobacterium tuberculosis in endemic areas.
• Cerebral toxoplasmosis remains the principal etiology of
intracranial space occupying lesions (SOL) and the number one
opportunistic infection of the nervous system in HIV patients
Sign and Symptom
Suggestive Examination

• CT facilitates  early detection, exact localization, and

accurate characterization, determination of number, size,
and staging of the abscess
• MRI  recognize pyogenic abscesses fairly accurately.
MRI findings also depend on the stage of the infection.
• Toxoplasma serologic test, biopsy, bronchoalveolar
lavage (BAL), acid-fast staining and culture for
mycobacteria  find the possible cause of the cerebral
abscess in order to initiate proper treatments.
Treatment

• Primary prophylaxis is recommended in HIV/AIDS where

the number of CD4 <100/mm3 or patients with CD4
<200/mm3 were accompanied by opportunistic infections
and malignancies.  Trimethoprim-sulfametoksazole
(TMP-SMX) in dose one double strength tablet (160 mg
TMP, 800 mg SMX) 2 times per day.
• Corticosteroids should be used in the treatment of brain
abscess to reduce cerebral oedema and so an altered level
of consciousness, reducing intracranial pressure and
avoiding acute brain herniation  Dexamethasone at 4
mg four times a day tapering over a few days
DISCUSSION
Basic clinical diagnosis

Secondary Headache

From Anamnesis :
• The patient has been complained that she has
a severe headache that is more worsening
progressively  cronic progresive pain.
• The patient has sa neurology deficite such as
seizure and lost of conciousness increasing
of intracranial pressure
Basic clinical diagnosis

Symptomatic Epilepsy

• Repeated seizure happen 3 times in 24

hours  epilepsy
• There is any abnormality or lesion of
brain cause of infection such as serebral
absess
Basic clinical diagnosis

Hemiparastesia Dextra

• From anamnesis the patient complained that

she feels any numbness at lower extremity
dextra  maybe cause of the lesion of brain
Basic topical diagnosis
Cerebri Hemisphere Sinistra

According to the anamnesis :

• The patient has loss her conciusness and
seizure Altered level of consciousness is
mostly found in some cases with central
nervous system (CNS) involvement.
• From the present illness history, the patient
also complained numbness on the right side of
the body and difficulties when walking.  any
lesion in cerebri hemisphere sinistra.
Basic etiological diagnosis

SOL ec susp. Cerebral

Abcess

• Patient has complained that she has severe pain that

is more worsening progressively, nausea, vomitting,
also sign of increasing intracranial pressure like
headache and loss of conciussness, following by
neurological deficite such as seizure and loss of
conciousness.  Space Occupying Lesion.
• In present ilness history there is fever, headache,
nausea, vomiting, altered level of conciuosness, and
neurological deficite such as seizure.  Cereberal
Abcess.
Basic differential diagnosis

SOL ec susp. Cerebral

Abcess

• Patient has complained that she has severe pain that

is more worsening progressively, nausea, vomitting,
also sign of increasing intracranial pressure like
headache and loss of conciussness, following by
neurological deficite such as seizure and loss of
conciousness.  Space Occupying Lesion.
• In present ilness history there is fever, headache,
nausea, vomiting, altered level of conciuosness, and
neurological deficite such as seizure.  Cereberal
Abcess.
Basic work up
Blood routine test  to find any change that show infection
Blood chemistry test and electrolyte  to find whether there is any
extracranial process involved
Serum IgG anti-toxoplasma  to detect anti toxoplasma antibody

Serum CD4 level  assessing patient’s immune status and associated to

the initiation of primary prophylaxis
Head CT Scan  to find intracranial cause of the altered level of
consciousness

Thoracic X-Ray  to find any other possible etiology

Funduscopy  to find papil oedem

EEG  to seen an electrical activities of brain for diagnose epilepsy

CSF Exam  to find any other infection

Basic treatment

• Cotrimoxazole is recommended as phophylaxis againts serious bacterial

infections in HIV-infected patients. Cotrimozaxole is a combination of
antibiotics that is containing trimetoprim and sulfamethoxazole..
• Ketorolac is an non steroidal anti inflamatory drug (NSAID) as an
analgetik for headache.
• Ondansentron is an anti emetic for nausea. Its inhibit the action of
serotonin, a chemical messenger that can trigger nausea and vomiting.
• Omeprazole is an proton pump inhibitor, it works by reducing the
amount of acid in the stomach which help in the relief of acid in the
stomatch which help in the relief of acid-related indingetion and
heartburn.
Basic treatment

• Phenythoin is an anticolvulsan which elevated the seizure threeshold in

the motor cortex by limiting the post tetanic potentiation of synaptic
transmission. Phenytoin in indicated for the treatment of generalized
tonucclonic status epilepticus, and prevention and treatment of seizure
accuring during neurosurgery.
• Dexamethasone as Corticosteroids should be used in the treatment of
brain abscess to reduce cerebral oedema and so an altered level of
consciousness. Corticosteroids are also recommended perioperatively for
reducing intracranial pressure and avoiding acute brain herniation.
• Paracetamol has been given as antipiretic for treating the fever.
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