Matthew T. Santa Barbara, MD; Timothy Anderson, MD; Marion A. Hughes, MD; Gregory M. Bump, MD
September 14, 2015
An 81 year old male with alcoholic cirrhosis complicated by portal hypertension with recurrent hepatic hydrothorax presented to the emergency department with epistaxis and altered mental status. The patient required 6 liters of oxygen via nasal cannula, but was otherwise hemodynamically stable. Physical exam was significant for decreased breath sounds and increased dullness to percussion extending to the right mid lung field posteriorly.
Laboratory analysis showed leukocytosis with an elevated neutrophil count. A non-contrast head computed tomography (CT) scan showed extensive paranasal opacification suggestive of acute bacterial sinusitis (Figure 1) as well as sinus wall thickening consistent with chronic sinusitis. A chest radiograph showed worsening of the patient’s chronic right-sided pleural effusion. He was started on intravenous antibiotics and admitted.
The patient’s epistaxis resolved. A therapeutic thoracentesis resulted in modest improvement in his oxygen requirements. However, on the fourth hospital day, worsening hypoxia and respiratory distress developed. The patient was transferred to the ICU and was placed on non-invasive positive pressure ventilation (NPPV). The following morning, the patient’s mental status deteriorated and he was found to have asymmetric pupils. A repeat non-contrast head CT was obtained and displayed below (Figure 2).
Click here to
view answer
References:
1. Kopelovich J, de la Garza G, Greenlee J, Graham S, Udeh C, O'Brien E. Pneumocephalus with BiPaP use after transsphenoidal surgery. Journal of Clinical Anesthesia 2012;24(5):415-418.
2. Kosac Vde A, Matta A, Prado F, Nascimento O, Matta G, Santos T. Tension pneumocephalus and rhinorrhea related to chronic sinusitis. Arq Neuropsiquiatr 2013;4:269.
Authors:
Matthew T. Santa Barbara, MD: Resident, Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center
Timothy Anderson, MD: Resident, Department of Medicine, University of Pittsburgh Medical Center
Marion A. Hughes, MD: Assistant Professor of Radiology, Division of Neuroradiology, University of Pittsburgh Medical Center
Gregory M. Bump, MD: Associate Professor of Internal Medicine, Division of General Internal Medicine, University of Pittsburgh Medical Center