Age: 17.0
Sex: F
Vaccine: TYP
Symptoms: Lumbar puncture normal, Mental status changes, Muscular weakness, Nuclear magnetic resonance imaging brain normal, Nuclear magnetic resonance imaging spinal normal
Clinical narrative: Initial unsolicited report received from the literature 02-Mar-2017. The following is verbatim from the article: Abstract: Introduction: Post-Dural Puncture Headache (PDPH) is a debilitating complication of lumbar puncture (LP) characterized by a vicious cycle of immobility, weakness and depression. Numerous treatments have been applied for the proper management of PDPH but their safety and efficacy still need improvement. Results/Case report: A 17 year old female with past medical history (PMH) x/o poly cystic ovarian disease (PCOD) and irritable bowel syndrome (IBS) was admitted to PICU with Altered mental status (AMS) and h/o of clonic movements In UE/LE's. Two days prior to presentation, the patient complained of B/L extremity weakness while at work. Later that day, symptoms progressed as she developed confusion and began experiencing spontaneous, clonic movements in all extremities. Patient denied incontinence or post-ictal period. Patient's father took her to an ED where they suspected dystonic reaction and administered diphenhydramine and then lorazepam (1 mg) which broke the movements. Labs were normal and urine toxicology was negative. The next day, patient was seen by pediatric neurology and had normal EEG. They determined that the etiology was unlikely to be neurological in origin and recommended follow up with ID. The evening prior to admission, the patient's clonic movements persisted and she began experiencing new onset visual hallucinations. In addition, the patient's mother also found two ticks (embedded, not engorged) on the patient's posterior knee and abdomen just prior to presentation in our ED. The patient had been hiking earlier in the week. On PE, no fever or rashes were noted. No recent travel history. The patient received Yellow Fever vaccine (4 weeks prior), Menactra and hepatitis A booster (10 days prior) and typhoid vaccine (PO 5 and 3 days prior). Patient reported feeling feverish for 3 days following her booster vaccines. LP, head CT w/o contrast, brain MRI w/ & w/o contrast and lumbar spine MRI w/ & w/o contrast were negative. During her stay in the PICU, patient developed a postural frontal headache suspected to be PDPH secondary to LP. Headache was effectively treated with sphenopalatine ganglion block (SPGB). Discussion: Therapeutic epidural blood patch (EBP) is currently the standard of care for post-LP cephalalgia with a success rate ranging from 68 percent - 90 percent. Epidural blood patches are known to be associated with negative sequelae, including subdural and epidural hematoma, needle trauma, back pain, meningitis, and a possible second dural puncture. Thus, we are advocating the use of sphenopalatine ganglion block (SPGB) as a first-line treatment for PDPHs. SPGB is a noninvasive anesthetic intervention with minimal adverse effects and high efficacy. It can be performed by inserting a cotton-tipped applicator saturated with 5 percent water-soluble lidocaine ointment through each nares bilaterally and positioning the end of the applicator tip just superior to the middle turbinate and anterior to the pterygopalatine fossa and sphenopalatine ganglion for 10 minutes with the patient In supine position. Acute stimulation of the SPG with good anatomical and physiological placement leads to rapid termination of severe headache. This case involves a 17-year-old female patient who was vaccinated with a YELLOW FEVER VACCINE 4 weeks prior, TYPHOID VACCINE per oral, 5 and 3 days prior, HEPATITIS A VACCINE, and MENACTRA 10 days prior (Dose, batch number, expiry date, route and site of administration was not reported) on an unknown date. The patient's had medical history of poly cystic ovarian disease (PCOD) and irritable bowel syndrome (IBS) was admitted to PICU and history of clonic movement in UE/ LE's. No recent travel history. The patient's concomitant medications were not reported. On an unknown date, following the vaccination, the patient developed altered mental status, postural frontal headache suspected to be PDPH secondary to LP, clonic movements in all extremities/clonic movements persisted, suspected dystonic reaction, visual hallucinations, confusion, B/L extremity weakness, and feeling feverish (for 3 days). The patient visited to ED. corrective treatment broke the movements. The patient's mother also found two ticks (embendded, not engorged) on the patient's posterior knee and abdomen. The patient was hospitalized on an unknown date. Relevant laboratory test results included labs were normal and urine toxicology was negative. Pediatric neurology and had normal electroencephalogram (EEG), LP, head computed tomography (CT) without contrast, brain magnetic resonance imaging (MRI) with and without contrast and lumbar spine magnetic resonance imaging (MRI) with and without contrast were negative. The patient received corrective treatment with diphenhydramine, lorazepam (1 mg) and sphenopalatine ganglion block (SPGB). The outcome of event was not reported. Reporter was stated that, the etiology was unlikely to be neurological in origin and recommended f/u w/ ID. Documents held by sender: none. Sender's Comments: Patient was vaccinated with YELLOW FEVER VACCINE, HEPATITIS A VACCINE, TYPHOID VACCINE and MENACTRA vaccines following which patient had pyrexia with headache post lumbar puncture, altered mental status, clonic movement, visual hallucination and dystonic reaction. The event might be due to complication of lumbar puncture, patient has history of tick bite which could be alternative etiology as tick borne disease may present with similar symptom, details regarding patient medical history, etiological work up, concomitant medication, and more investigation results to rule out the alternative cause are needed for complete assessment of the case. Based on available information no conclusion can be drawn.