Thread by @hyderabaddoctor

Case of a woman in whom “Runny Nose” was caused by a Brain Disease

1. 35-year-old woman presented with intermittent #runny #nose and #headache of one month duration.
Local physician suspected #sinus infection, treated her with a course of antibiotics, with which she improved.

2. Symptoms recurred one week back after which she consulted me for a “permanent cure of her sinus infection”.
I decided to delve deeper into the history.
#MedTwitter #neurotwitter

3. Runny nose occurred only from left nostril. It occurred 4-5 times per week.
Discharge from nose was watery and it increased on bending the head downwards.

4. On enquiry, she revealed that she had slipped and fallen in bathroom about two months ago. She had mild headache after that, which subsided with paracetamol. She didn’t consult any doctor then.

5. By now, my facial expression was turning serious, but the patient seemed in a hurry- “Doc, write some medicines for the nasal allergy & sinus; I will be fine”.
On the other hand, I was thinking of a serious brain disease.

6. I requested her to go for high resolution CT scan of brain. She returned in an hour with the report- “bony defect noted in cribriform plate of ethmoid bone on left side”.
Through this defect, cerebrospinal fluid (CSF) was leaking through her left nostril.

7. The mystery was only partly solved. We still needed to find the reason for headache.
If CSF from brain can leak into nose; in a similar fashion, bacteria from nose can enter into CSF, causing “brain fever”.

8. I asked for lumbar puncture and CSF analysis, which confirmed bacterial meningitis.
So, the final diagnosis was- Fracture in Cribriform plate of ethmoid bone (due to mild head injury), with CSF leak, and bacterial #meningitis.

9. She was treated with a 2-week course of IV antibiotics.
Subsequently, she underwent a surgery to repair the CSF leak site.
She recovered well and remained symptom-free after three months of follow up.

10. Take home message:
*Discharge of clear fluid from nostrils, aggravated with change of head position, especially after a head trauma needs to be investigated for a CSF leak.

*Early recognition & prompt treatment can result in excellent outcome and prevent complications.

Learning points for medicos
1. Bacterial meningitis (partially treated, as in this case) can present with just headache, without any fever, drowsiness, vomiting, and other signs of being acutely sick.
The classical triad of meningitis has poor diagnostic sensitivity/specificity.

2. CSF leak can occur with trivial head trauma. In many cases, patients do not even remember any such fall or trauma. In some cases it can be spontaneous too.
High index of suspicion is needed to diagnose CSF leak as well as meningitis.