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Four-year-old boy with headache, swollen forehead



THE CASE

A 4-year-old boy presents to your clinic one autumn, along with his mom and dad, with a 6-month history of headaches and the recent appearance of a tender lump in the middle of his forehead. His parents report that the headaches have been episodic and bifrontal. The pain is localized to just above the bridge of his nose and radiates between his eyes to his scalp.

He asks for the room to be darkened because the light hurts his eyes. He has had a runny nose this spring and summer, which mom and dad attribute to seasonal allergies. He denies head trauma. He has obvious periorbital edema and also a doughy swelling over his glabella. He is not febrile.


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The boy was admitted to the children's hospital 20 days ago for a case of severe sinusitis. He presented to the emergency department at that time with fever, headache, irritability, photophobia, and new nonfluctuant forehead swelling. You review the blood work from that evaluation. The white blood cell count was elevated at 20,000 cells per liter (normal, 4,500 to 10,000 cells/L) and left shifted with 73% granulocytes and 0.4% bands. The erythrocyte sedimentation rate was 24 mm/hr (normal, 0-10 mm/hr) and C-reactive protein was 2.7 mg/dL (normal, 0-0.9 mg/dL). Two peripheral blood cultures yielded no growth.

You review the head and sinus computed tomography (CT) scans obtained during the admission and readily appreciate the severe pansinusitis and marked thinning of the lateral walls of the ethmoid air cells. Midline soft tissue swelling was present anterior to the frontal sinuses, but no erosion into these structures was evident. There was no abscess.

The patient was treated with 4 days of intravenous piperacillin-tazobactam, oral phenylephrine, and nasal oxymetazoline in the hospital. The mother says that both the headache and the swelling transiently improved with these interventions. He was discharged home to complete a 21-day course of amoxicillin-clavulanate. The headaches and forehead swelling improved.

Digging a little deeper

You further investigate by obtaining a detailed headache history. Headaches began 6 months ago and initially occurred twice per week. They begin in the midafternoon and last approximately one-half to 1 full hour. For the past 2 months, the headaches have occurred almost daily. They begin suddenly. The headaches occasionally wake the patient from sleep.

There is no associated nausea or vomiting. By his parents' report, there has been no altered mental status. They deny cognitive or behavioral regression. There have been no changes in gait or baseline energy.

Nine weeks ago, the patient began to experience intermittent fevers approximately 3 times per week, with a maximum temperature of 40C. The fevers resolve by late evening.

The patient has been evaluated on numerous occasions by his primary care pediatrician for the headaches and the fevers and was referred to neurology because of the increased frequency of paroxysmal headaches. An electroencephalogram was found to be normal.

On this day

You are seeing the patient today because his forehead swelling and headaches returned after 3 weeks. The family completed the amoxicillin-clavulanate course 1 week ago, but the patient's headache and photophobia recurred 2 days ago. The forehead swelling was noted at bedtime yesterday. The patient also reports that he wasn't able to see out of his right eye twice that morning. He says he can see fine now. He has had no fever since hospital discharge. He has had no nausea or vomiting.

Happy patient, concerned doctor

The energetic patient runs around the room as though nothing were wrong. He is afebrile, with a normal growth curve. His vital signs are within normal range for his age. He is oriented to time, place, and person. His memory is intact, and his speech is fluent. You palpate a 3 cm 3 cm, well-circumscribed, skin-colored, fluctuant, tender midline forehead mass. He has mild periorbital swelling.

Alarmed by the history of right-sided vision loss, you perform a thorough eye exam. The pupils are equal, round, and reactive to light. There is full ocular motility. There is no conjunctivitis. There is no nystagmus or ptosis. Using a panoptic ophthalmoscope, you confirm that the retinas appear normal, and the disks are sharp. The tympanic membranes, ear canals, and periauricular tissues are normal. The mastoid process is nontender and nonedematous. The boy has excellent dentition. His neck is supple. Lymphadenopathy is absent. The remainder of his neurologic and physical examination is unremarkable.


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