A 12-year-old boy is brought to the office for fever. Two weeks ago, he developed rhinorrhea, sore throat, and cough. For the past 2 days, the patient has had a fever and progressively worsening pain behind his eyes that radiates to his right forehead. He woke early this morning and vomited twice. He has had no diarrhea. The patient has no chronic medical conditions and takes no daily medications. Temperature is 39.7 C (103.5 F), blood pressure is 134/86 mm Hg, pulse is 116/min, and respirations are 26/min. The patient appears drowsy and uncomfortable. Examination shows copious green nasal discharge from the right naris. Palpation of the right forehead elicits tenderness. Oropharyngeal examination shows erythema along the posterior oropharynx with purulent drainage. The neurologic examination is nonfocal. Which of the following is the best next step in management?
Show Explanatory Sources
This patient's focal headache, fever, and early-morning vomiting in the setting of a sinus infection are concerning for a brain abscess due to the contiguous spread of bacteria from the frontal sinus.
Acute bacterial rhinosinusitis (ABRS) is a common infection of the paranasal sinuses that typically presents with ≥10 days of upper respiratory symptoms (eg, cough, congestion, sore throat) with or without fever. Localized sinus tenderness may be elicited on palpation, as seen in this patient. Untreated ABRS can lead to life-threatening complications such as periorbital/orbital cellulitis due to orbital extension as well as meningitis or brain abscess due to intracranial extension.
Intracranial complications should be suspected in patients with persistent headache and early-morning vomiting, which occurs due to increased intracranial pressure in the recumbent position. Other findings may include altered mental status (eg, drowsiness), neck pain (suggestive of meningeal irritation), and focal neurologic deficits.
The next step in management is urgent imaging of the brain, orbits, and sinuses. Although MRI is more sensitive, CT scan is faster and can detect early cerebritis; a ring-enhancing lesion confirms the diagnosis. Treatment is intravenous antibiotics and surgical drainage.
(Choice B) Lumbar puncture is indicated for suspected meningitis, which can cause fever, diffuse headache, and vomiting. However, when elevated intracranial pressure is suspected, neuroimaging should precede lumbar puncture because of the risk of cerebral herniation. Therefore, this patient's early-morning vomiting and focal headache warrant imaging prior to cerebrospinal fluid evaluation.
(Choice C) Culture obtained by sinus aspirate is often indicated in complicated ABRS for pathogen identification and antibiotic therapy guidance. However, nasopharyngeal culture does not reliably correlate with culture from sinus aspirate.
(Choice D) Acute viral rhinosinusitis is treated with supportive care, including nasal saline and irrigation, nonsteroidal anti-inflammatory drugs (NSAIDs), and reassurance. Symptoms (eg, cough, rhinorrhea, low or no fever) typically resolve by day 10, unlike in this patient, who has progressive symptoms suggestive of complicated bacterial infection.
(Choice E) Oral antibiotics (eg, amoxicillin, amoxicillin-clavulanate) are indicated for uncomplicated ABRS. This patient has symptoms indicating intracranial extension of infection and requires intravenous antibiotics.
Educational objective:
Untreated acute bacterial rhinosinusitis can lead to intracranial extension of infection, such as brain abscess. Symptoms include focal headache, early-morning vomiting, altered mental status, and/or focal neurologic changes. Urgent CT scan of the head reveals a ring-enhancing lesion.