"In the deep midwinter," a teenager's headache and cranial-nerve findings leave you cold

November 1, 2006

An adolescent girl complains of headaches and presents with lateral-gaze paralysis of the right eye. Can you solve this mystery?

DR. RALSTON is an assistant professor of pediatrics and a pediatric hospitalist and DR. SINGLETON is a resident in pediatrics at theUniversity of New Mexico Children’s Hospital, Albuquerque.DR. MOTT is a resident in family practice medicine at University of New Mexico Health Sciences Center, Albuquerque.DR. SIBERRY is an assistant professor of pediatrics in the divisions of general pediatric and adolescent medicine and pediatric infectiousdiseases at Johns Hopkins Hospital, Baltimore.The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that mayhave an interest in any part of this article.

It's but a few days after your return from winter break when you are called to the clinic to admit a 16-year-old girl who is complaining of headache and diplopia. Headache is a common presentation in adolescents, but a report of diplopia has you worried.

When you arrive bedside to evaluate your new patient, it's immediately clear that she has lateral-gaze paralysis of the right eye. Worse, she has a 10-day history of headache, which she describes as dull, frontal, and made worse with movement. She describes the headache as causing her to feel "unsteady" when walking but tells you that it hasn't interfered with sleep.

A deeper dig into the history isn't reassuring. The patient does not report a personal or family history of migraine. She is active in sports and is an excellent student who does not relate any significant stressors. Her sisters are home from college for winter break and are not sick; neither are her parents.

The medical history could not be more normal, including menarche at 12 years of age. The girl takes only acetaminophen, no more than twice a day, for the headache. You press her about use of vitamins or acne creams, but she insists that she uses neither.

Her only remarkable travel history is that she lived in Korea for a few years because her father is in the armed forces. She has not traveled outside the United States during the past year, however.

On physical exam, your patient appears relatively comfortable. Blood pressure is 100/60 mm Hg; heart rate, 75/min. Height and weight are both at the 75th percentile for age.

Cranial-nerve examination reveals sixth cranial-nerve palsy on the right side without other cranial-nerve deficits. Funduscopic examination is worrisome for bilateral papilledema. The remainder of the neurologic exam is unremarkable, including a down-going Babinski sign bilaterally and normal gait when the affected eye is patched.

You do not detect significant lymphadenopathy or hepatosplenomegaly. Examination of heart and lungs is unrevealing. A complete blood count, drawn at admission, is unremarkable.

The thing that worries everyone

Given the persistent headache, papilledema, and cranial-nerve findings, you can't smile as you explain the differential diagnosis to the patient and her mother. You are worried, you tell them, that some entity is raising the intracranial pressure. Her mother quickly surmises: What you are most worried about is a brain tumor.

You wonder to yourself about viral meningitis and its ability to cause cranial-nerve paralysis. But you know that most cases of viral meningitis are caused by enteroviruses and occur during warm months. You consider multiple sclerosis, acute disseminated encephalomyelitis, and other demyelinating processes; is it possible that you are interpreting signs of optic neuritis as papilledema? Briefly, you entertain a subarachnoid hemorrhage. Could she have pseudotumor cerebri? She is certainly not overweight.

You recheck the medication history to be certain: Again, no minocycline, no tretinoin (Retin-A) cream-nothing to cause concern at all.

Given the high level of concern about a brain tumor, you're able to work the patient in quickly for magnetic resonance imaging. She is in the scanner within a few hours of your initial evaluation.

Afterward, the neuroradiologist calls quickly-but not with the bad news you expect. He is upset that you sent a patient with metal-alloy orthodontic braces for an MRI scan, but he is able to tell you that she does not appear to have a brain tumor or any evidence of increased intracranial pressure. Regrettably, however, those braces make it impossible for him to tell you anything about the cranial nerves or the base of the brain.