14-year-old Male with Headache, Vomiting, and Fever Who Presents to the Emergency Department with Right Hand Tingling and Weakness – Code STROKE!

Introduction: Neurologic symptoms in pediatric patients can be very nonspecific and require broad differential diagnoses early on. Focal deficits trigger activation of Code STROKE, but it is important not to narrow the differential too early. While it is important to rule out the most serious/emergent conditions first, it is crucial to maintain broad differentials so that premature focus on one condition doesn’t lead to anchoring bias and ignoring another equally morbid one.

Case Description: A 14-year-old adolescent male presents with 3 weeks of dizziness, headache, vomiting, and blurry vision. He developed a cough, fever, new onset right hand tingling/weakness, and was sent straight to the ED. He also complained of sharp lumbar back pain and neck stiffness for one month. All other review of systems was negative. His neck was supple without meningismus. He had mild paraspinal tenderness in the lumbar region but had normal rectal tone.

On neurologic exam, he was alert was alert and oriented to person, time, and place, and demonstrated appropriate mood and affect. Cranial nerves II-XII were intact. He had 5/5 strength in all extremities except for 4/5 strength in the right hand. He had normal sensation in all extremities but endorsed tingling of the dorsal right hand during the examination. He had normal gait and coordination.

An hour later, he had an acute onset of left-sided facial droop, left arm pronator drift, and altered mental status, at which point Code STROKE was activated. Initial labs were notable for leukocytosis with eosinophilia, but otherwise unremarkable. An extensive hematologic and rheumatologic work-up was also performed and within normal limits. Imaging results were notable for a CT brain that showed no midline shift or hemorrhage, chest X-ray demonstrated extensive left lung infiltrate, and the MRI brain below (Figure 1).

Given his neurologic symptoms, a lumbar puncture was performed, which confirmed Cryptococcus gattii meningitis (CGM). He was started empirically on intravenous fluconazole and amphotericin B. Additionally, many of his symptoms were due to elevated intracranial pressure (ICP), so he underwent daily LPs to minimize his ICP.

Discussion: Cryptococcus gattii tends to affect younger, immunocompetent hosts. The most common neurologic manifestations of CGM are headache, stiff neck, fever, and presence of visual changes. Stroke-like symptoms have never previously been described as presenting signs/symptoms for CGM. Literature for pediatric strokes is quite limited. Initial symptoms of strokes in the pediatric population include seizures, altered mental status, headaches, and vomiting, all non-specific symptoms of other non-stroke conditions.

Conclusion: This case serves as a unique window into both pediatric stroke codes as well as rare infectious illness with CGM.