History of Present Illness:

This is a 35-year-old female presents with 2 days gradual onset posterior headache a little bit more on the right side with some nausea but no vomiting and some intermittent slightly blurred vision and just feeling shaky. No sudden onset. No trauma. No weakness no numbness no change in balance or vision. No other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for a heart rate persistently elevated in the 110-120 range.  Physical exam is otherwise normal including no photophobia, meningismus or focal neuro findings

Initial Diagnostic Testing:

  • CBC: WBC 16
  • Chem 7: normal
  • ID: viral swab negative but UA showed 100 WBC with clumps and rare bacteria.  It eventually grew >100K E. coli

What additional testing should you consider? (may select more than one)

  1. Influenza swab
  2. Head CT
  3. UA
  4. Chem 7

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ANSWERS: 

  1. Influenza swab
  2. Head CT
  3. UA
  4. Chem 7

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CASE CONCLUSION: Sent home on antibiotics.  Urine culture positive.  Headache gradually resolved over next 3-4 days

CASE LESSONS:

  1. Pyelonephritis is not typically considered a cause of isolated headache, but occasionally it can be.  Often is such cases there will also be fever and even vomiting but no flank pain, such that it mimics meningitis, but as this case demonstrates pyelo can present as headache alone without other symptoms.