Difficult Diagnosis: Brain Teaser
How a simple headache becomes complicated in the blink of an eye.
You don’t have to work in health care to know that much of what rolls through emergency room doors isn’t emergencies. That can be especially true when the patients are children: ear infections. Viruses. Fevers. Sore throats. Parents can be forgiven for being overprotective, but according to pediatric emergency medicine doctor Christine Darr, some parents have a very good reason for coming to see her.
When seven-year-old Bayla Nelson came into the emergency department on a weekend a few years ago, her parents were concerned. The youngster had been feeling ill for eight days. She’d had a fever, been vomiting, and complained of a persistent headache. They’d taken her to see the pediatrician, but that doctor had given her IV fluids and thought she’d feel better in a few days. The following day, however, their daughter was feeling so poorly that her parents called the pediatrician back. The doctor advised them to visit the emergency room.
When Dr. Darr first laid eyes on the patient, she’d initially considered strep throat. Things like pneumonia and a urinary tract infection were on the physician’s list of possibilities as well. But a strep test, a urine dip, and a chest X-ray came back negative. One of the girl’s symptoms in particular bothered the doc. “Younger kids tend not to complain of headaches very often,” Darr says. “When a prepubescent child complains of a headache, it’s usually something to pay attention to.”
Darr did a quick test on Bayla’s eyes, specifically looking for her optic disc. It wasn’t visible—a conclusive sign of increased intracranial pressure. Darr wanted to order an MRI, but the test wasn’t immediately available in the ER on the weekends. She requested a CT scan of Bayla’s head instead.
The radiologist called with results 10 minutes later. A dark spot had turned up on Bayla’s left frontal lobe. Although the spot could have been a brain tumor, Darr felt the patient’s symptoms were more consistent with a brain abscess, a pocket of bacteria-laden pus, and started the girl on IV antibiotics. One of the most common reasons for an abscess is a severe case of sinusitis, but Bayla hadn’t experienced sinus problems. There had to be another reason for the abscess, even though the doctor knew finding exact causes for infections like these is rare. Darr called a pediatric neurosurgeon and admitted Bayla to the hospital.
After multiple procedures and tests, doctors determined Bayla had patent foramen ovale, a hole in her heart that had allowed bacteria to seep into her bloodstream. By happenstance, that bacteria set up residence in the girl’s brain.
“This stuff is what makes the job interesting,” Darr says. “The thing about emergency medicine is that there’s always something new coming in, so you have to keep your mind open to the possibility it could be something more than a cold or an earache.” Of course, these diagnoses aren’t common: In any given year, Darr says she makes only a handful of unusual diagnoses. But, as Darr points out, answers to medical questions are sometimes just the beginning. After Darr diagnosed the abscess, neurosurgeons inserted a drain to reduce the pressure in Bayla’s brain, and cardiac surgeons went in to sew up the hole in her heart.