Case Based for April

A 74-year-old female presented to the ED with complaints of left-sided weakness for 24-36 hours. EMS reports they have been to the house three times in the past 2 days for lift assist. She denies any injury from falls, says they were all from trying to stand and sliding back down the couch. The patient says she had COVID several months ago and has had generalized weakness, brain fog, and malaise that have persisted. She complains of a right frontal headache. She was nauseous and vomited several times today. She denies numbness or tingling, no vision or speech changes. She developed a productive cough the day prior and had occasional wheezing.

History- asthma, HTN, morbid obesity. Nonsmoker, non-drinker. Lives with daughter and SIL. Retired.

Vitals BP 172/91, P 64, T 97.8, R 22, SpO2 96% on RA.

Exam- Gen- no acute distress; HEENT- unremarkable; CV- regular with 3/6 systolic murmur; Pulm- clear bilat; Abd- soft, obese, ND/NT; Neuro- left facial droop, mild dysarthria. Weakness R leg > R arm and distal > proximal. Pronator drift on the right. Ataxia right arm and leg

Labs- WBC 11.8, Alk phos 121. Lactic, TSH, trop, INR, COVID/flu, UA normal

Rad- CTA head/neck- 5 cm rim enhancing lesion right frontal lobe with 1.9 cm left shift and subfalcine herniation concerning for malignancy, metastasis, or abscess

On chart review, patient had been seen multiple times prior to arrival at our facility:

• She was seen at an ED in Spokane almost 2 months prior for facial pressure and ear pain, diagnosed with acute sinusitis and otitis media and treated with 7 days of Augmentin, ENT referral sent.
• She was seen at different outside hospital 5 days later with fatigue, persistent headache, and difficulty getting dressed. Afebrile, VSS, recommended complete abx, Flonase, saline rinses, Tylenol, get ENT appt.
• She was seen again 12 days later (~5 weeks prior to visit) with headache and weakness, was found on the floor in front of the sofa where she had been for 11 hours. Afeb, VSS, CXR and labs normal. No other imaging.
• Office visit with PCP 3 days later, continued headache, weakness, recommended outpatient PT.
• Televisit with PCP 2 weeks later (3 weeks prior to presentation) and patient reported slow improvement and she was able to stand by herself.

Course- radiologist called with CTA findings. I called the transfer center to consult with neurosurgery. They reviewed images and felt the lesion communicated with the sinus and favored abscess. Recommended not to start antibiotics until they get surgical cultures. Patient transferred to ICU at Sacred Heart.

After transfer, she had craniotomy and washout with drain placement. They found purulent drainage under pressure and cultures obtained. She was started on metronidazole, ceftriaxone, and vancomycin. Cultures grew Strep intermedius. Narrowed antibiotics to ceftriaxone and metronidazole x 8 weeks.  Transferred to St Luke’s for rehab 1 week later. Discharged home on ceftriaxone daily and oral metronidazole after 2 weeks, to complete IV/oral antibiotics after 8 weeks, then transitioned to Augmentin x 4 weeks. Four months later, had endoscopic sinus surgery/tissue removal.

Take home point: Acute viral rhinosinusitis (AVRS) and acute bacterial sinusitis (ABS) have symptoms that overlap. ABS usually has a “double sickening” biphasic pattern of illness and symptoms lasting longer than 10 days. Purulent nasal discharge and facial pain do NOT indicate bacterial vs viral infection. The “sweet spot” for not overtreating viral illness with antibiotics and not allowing complications from untreated sinusitis to occur is small. Complications are rare but are significant when the bacterial infection spreads beyond the sinuses and nasal cavity and penetrates the orbit, surrounding tissues, or CNS. Complications include preseptal (periorbital) cellulitis (eyelid swelling and pain), orbital cellulitis (same swelling plus pain with eye movement, proptosis, diplopia, visual impairment), subperiosteal abscess, osteomyelitis of the sinus bones, meningitis, intracranial abscess, and septic cavernous sinus thrombosis.

Treatment for most people consists of regular dose amoxicillin or amoxicillin-clavulanate. If the patient has risk factors for resistant pneumococcus (age > 65, hospitalized or treated with antibiotics in the past 3 months, immunocompromise, multiple comorbidities [DM, CAD, CKD, hepatic disease] or severe infection [evidence of systemic toxicity or concerns for suppurative complications], high dose amoxicillin-clavulanate is recommended. For penicillin-allergic patients, treat with doxycycline or 3^rd generation cephalosporin + clindamycin. For people who can also not tolerate above agents, respiratory fluoroquinolone (levofloxacin 750 mg or moxifloxacin 400 mg daily). Macrolides and sulfa/trimeth are NOT recommended because of high rates of resistance.

Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis – UpToDate

Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment – UpToDate

Written by Sara Ragsdale, D.O.

ERx Clinical Partners Medical Director

This is for informational purposes only. For medical advice or diagnosis, consult a physician