Rosen & Barkin's 5-Minute Emergency Medicine Consult (733 page)

• Physical exam findings are normal; if abnormality found, consider other cause
  
• Carefully examine head and neck, with emphasis on CNs
  
• Patient’s report of pain following stimulation of a trigger point is pathognomonic
  

• Diagnosis is made clinically
  
• Clinical features to differentiate classical and symptomatic disease:
  
  • Age on onset <50 yr
    
  • Sensory deficits
    
  • Bilateral involvement
    

No specific lab tests apply

• Patients with characteristic history and normal neurologic exam may be treated without further workup
  
• If dental problems are suggested, dental radiographs may be useful
  
• MRI brain/CT head may be useful if multiple sclerosis or tumor is suggested:
  
  • May be useful in initial presentation
    

• Multiple sclerosis
  
• Temporomandibular joint syndrome
  
• Glossopharyngeal neuralgia
  
• Compression of trigeminal root by tumors
  
• Dental problems/pain
  
• Cluster headache
  
• Postherpetic neuralgia
  
• Sinusitis
  
• Otitis media
  
• Temporal arteritis
  

TREATMENT

• Appropriate pain relief
  
• Medical therapy:
  
  • Carbamazepine most commonly used
    
  • Other antiepileptics show some support as adjuvants for refractory pain.
    
• May need neurosurgical evaluation for treatment and/or exploration
  

Carbamazepine: 200–800 mg/d PO BID

• Gabapentin: Start 300 mg PO QD
  
• Lamictal: Start 25 mg PO QD
  
• Oxcarbazepine: 450–1,200 mg PO BID; start 300 mg PO BID
  
• Phenytoin: 300–400 mg/d div. QD–TID
  
• Valproic acid: Start 250 mg PO BID
  

FOLLOW-UP

• Trigeminal neuralgia with presence of other focal neurologic findings
  
• Positive CT or MRI studies may require emergent neurologic or neurosurgical consultation
  
• Refractory or recurrent trigeminal neuralgia not responding to outpatient pain management or anticonvulsant therapy:
  
  • May require admission for surgical intervention and ablation of the trigeminal nerve
    

Patients without any focal neurologic findings and improved pain control in the ED may be managed as outpatients.

• Surgical therapy may be indicated for those who fail medical treatment
  
  • Pain relief in 85–90%
    
• Referral to a pain management center may be helpful in cases of refractory pain
  
• Anesthetic blocks of the trigeminal ganglion may be helpful
  

• Follow up with PCP or neurologist for treatment
  
• Referral to a neurosurgeon may be indicated for refractory pain:
  
  • Percutaneous vs. open surgical treatment
    

• Unilateral, paroxysmal, and sharp/stabbing facial pain, following a portion of CN V distribution
  
• Trigger points are pathognomonic
  
• Do not miss an alternate (nonvascular) cause of nerve compression, such as CNS mass or aneurysm
  
• Carbamazepine is the most common treatment
  

• Garg RK, Malhotra HS, Verma R. Trigeminal neuralgia.
  J Indian Med Assoc
  . 2011;109:631–636.
  
• Krafft RM. Trigeminal neuralgia.
  Am Fam Physician
  . 2008;77:1291–1296.
  
• Siqueira SR, Teixeira MJ, Siqueira JT. Clinical characteristics of patients with trigeminal neuralgia referred to neurosurgery.
  Eur J Dent
  . 2009;3:207–212.
  
• Wolfson AB, Hendey GW, Ling LJ, et al., eds.
  Harwood-Nuss’ Clinical Practice of Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  

CODES

• 053.12 Postherpetic trigeminal neuralgia
  
• 350.1 Trigeminal neuralgia
  

BASICS

• Tuberculosis (TB) is an infectious disease with protean manifestations, causing significant global morbidity and mortality.
  

• Infectious droplet nuclei are inhaled through the respiratory tract.
  
• Bacteria are dispersed through coughing, sneezing, speaking, singing.
  
• Primary TB/latent TB infection (LTBI):
  
  • Initial infection occurs when organisms enter the alveoli, become engulfed by macrophages, and spread via regional lymph nodes to the bloodstream.
    
  • Patients are usually asymptomatic.
    
  • May be progressive/fatal in immunocompromised hosts.
    
  • Positive reaction to purified protein derivative (PPD) indicates past exposure or infection.
    
  • Negative PPD does not rule out active TB.
    
  • May progress to active TB (5–10%).
    
• Reactivation TB:
  
  • LTBI becomes active TB.
    
  • Systemic (15%) and pulmonary (85%) symptoms.
    
• TB affects about one-third of the world’s population (90 million new cases in the past decade worldwide, with about 30 million deaths).
  
• Centers for Disease Control and Prevention (CDC) statistics from 2011 show TB in US at an all-time low.
  
• TB rates in US have continued to decline since 1993.
  
• Increase in US foreign-born cases
  
• Still an estimated 10–15 million people are infected in US alone.
  

• Infection with
  Mycobacterium tuberculosis,
  a slow-growing, aerobic, acid-fast bacillus resulting in disease.
  
• Humans are the only known reservoir.
  
• Recent TB epidemics:
  
  • HIV-infected patients
    
  • Multidrug-resistant TB (MDR-TB)
    
  • Extensively drug-resistant TB (XDR-TB):
    
    • High mortality, few effective drugs
      

DIAGNOSIS

• Depending upon site of infection; all human tissues have potential for infection.
  
• Pulmonary TB:
  
  • Cough
    
  • Fever, night sweats
    
  • Malaise, weight loss
    
  • Hemoptysis
    
  • Pleuritic chest pain
    
  • Shortness of breath
    
• Extrapulmonary TB:
  
  • CNS infections:
    
    • Meningismus
      
    • Cranial nerve defects, diplopia
      
    • Headache, fever, malaise
      
    • Confusion
      
    • Acute ischemic stroke
      
  • Pericarditis:
    
    • Pleuritic chest pain increased with recumbency
      
  • Renal infection:
    
    • Fever
      
    • Flank pain
      
  • Spinal TB (Potts disease):
    
    • Back pain/stiffness, point tenderness
      
    • Fever
      
    • Decreased range of motion
      
  • Cervical lymphadenitis (scrofula):
    
    • Unilateral, painless
      
    • May form draining sinus tracts
      
  • Miliary TB:
    
    • Multiorgan system involvement
      
    • Diffuse adenopathy
      
    • Hepatomegaly
      
    • Splenomegaly
      
    • Weight loss, fever
      

Predisposing factors and conditions for TB:

• HIV infection and other immunocompromised states (organ transplant, renal failure, diabetes)
  
• Drug and alcohol abuse
  
• Poverty, homelessness (living in shelters)
  
• Institutionalization (nursing homes, prisons)
  
• Immigration from an endemic area
  
• Positive PPD test/previous infection