Space Occupying lesion
A 82yr old man who lives alone presents to the Emergency Department brought in by a neighbour, with a 4hr history of seizures. He’s had at least two episodes, each lasting just about a minute.
The neighbour states that he has been generally unwell for the past 3 weeks and been ‘acting more confused’ over that period of time
He has a CT scan as shown below:
Sorry about the quality but thoughts on differentials and management!
Munanga
Presenting complaint:2 issues need addressing in this dude, hx of seizures and the CNS lesion on head CT. It is hard to see clear details of the lesion or whether there are multiple lesions. differential diagnoses for seizures in an elderly gentleman such as the one above include degenerative conditions such as Alzheimers’, stroke, parkinson’s or tumors and infections. We do have a CNS lesion in this patient, so that may be more to be etiology of his seizures. Moving on to the differential for the lesion: the differential is fairly wide, will just mention a few. Information that would be helpful includes presence of other focal neurological deficits, hx of travel or the geographic location where the pt actually lives, exposures to parasites, mycobacteria etc and HIV, though the latter is highly unlikely given his age.
ASSESSMENT: Possible causes include
1. Tumor- primary or metastatic (esp if there are satellite lesions).
2. Infectious etiology such as brain abscess, mycobacterial infection, fungal or parasitic infection like cysticercosis.
PLAN.
1. Brain MRI with and without contrast.
2. i. If it is a tumor, the dude will need biopsy unless a primary site is found in the case of metastatic cancer and in that case, treatment will depend on the characteristics of the primary cancer.
ii. If it is an infectious cause, again we do need tissue obtaining either via stereotactic biopsy or craniotomy and specimens be sent for aerobic, anaerobic, fungal and mycobacterial cultures as well as gram stain. Serologies can also be sent looking for various parasitic infections. Definitive treatment will depend on what the biopsy shows. Antibiotics versus ATT ( I hope that’s what is still called)
If this is in Zambia of course, just go ahead and treat the patient with IV antibiotics empirically and if no improvement, consider anti TB therapy and monitor for improvement. He would also need antiseizure medication. question is” Would you do an LP?”
Sorry if this is too long, got carried away…
Nice one - you got carried away just long enough!!
Well might I add he also presented with low grade fevers!!!
Does that narrow it down?