Intractable/ Persistent Hiccups Due to Acute Subdural Haemorrhage as a Result of Prolonged Inr in a 55 Year Old Man with Rheumatic Mitral Valvular Heart Disease and Atrial Fibrillation: A Case Report

A 58 year old man was brought to hospital in state of deep coma following severe headache for one day. His GCS was 3/15 and had flaccid all 4 limbs with equivocal planter response on both sides on arrival. NECT head showed acute subdural haemorrhage with surrounding cerebral oedema, mid-line shift and corning of brain stem. After giving mannitol and dexamethasone, four hours later, he became fully conscious and orientated; his motor power returned to normal. He was on warfarin 3mg daily for rheumatic mitral valvular heart disease with atrial fibrillation and his INR on arrival was 3.5. He had intractable hiccups once he regained consciousness. Both pharmacological and non-pharmacological measures were tried for distressing hiccups; there was no therapeutic success. His hiccups disappeared completely only after removing the haematoma by burr hole surgery.

Ocular and Facial Herpes Zoster and Meningitis in an Adult after Zoster Vaccination

Purpose: To report a case of ocular and facial herpes zoster and meningitis after herpes zoster vaccination.Case summary: A 60-year-old man was administered Zostavax® on his left arm; he developed a vesicular rash over his left eye and forehead 4 days afterwards. He started antiviral drugs for the rash, and visited the hospital for severe headache and spread of the rash to involve the tip of his nose, face, and palate by day 7. He was taking Synthyroid® (Bukwang Pharmaceuticals, Seoul, Korea) since his thyroidectomy for thyroid cancer 6 years ago. He had never been diagnosed with chickenpox, but had an episode of red facial rash in childhood. Slit-lamp examination revealed conjunctival chemosis, hyperemia, and a pseudodendrite in the peripheral cornea. The anterior chamber was quiet, and there were no significant findings on his brain magnetic resonance imaging. Varicella zoster virus was detected in the cerebrospinal fluid by polymerase chain reaction. The patient was treated with oral acyclovir drugs and topical ganciclovir, levofloxacin, and bromfenac. One week later, the pseudodendrite disappeared and conjunctival chemosis improved. There was no recurrence during 6 months follow-up.Conclusions: Reactivation of ocular or facial herpes zoster or meningitis after zoster vaccination may occur, rarely. Immediate antiviral treatment is required in these cases.

Persistent Headache Caused by Post-Traumatic External Nasal Neuralgia: A Case Report

A 50-year-old female patient presented with a severe headache characterized by sharp pain localized in the right frontal area above the right eye. The patient’s right nostril was cauterized to stop a nosebleed one year prior to the start of the pain. Physical examinations revealed that the pain was aggravated by touch of the right lateral side of the nose and in severe attacks radiated to the maxillary frontal teeth. Blood tests, magnetic resonance image (MRI) and computer scanning (CT) scan images were all normal. The patient was diagnosed with post-traumatic external nasal neuralgia and symptoms were relieved and nearly resolved completely using a nasal cleanse and lubrication of the nose.

PP296 Patient Involvement In An Assessment Of The Management Of Sudden Onset Severe Headache Presenting To The Emergency Department

IntroductionSudden onset severe headache is usually caused by a primary headache disorder but may be secondary to a more serious problem, such as subarachnoid hemorrhage (SAH). Very few patients who present to hospital with headache have suffered a SAH, but early identification is important to improve patient outcomes. A systematic review was undertaken to assess the clinical effectiveness of different care pathways for the management of headache, suspicious for SAH, in the Emergency Department. Capturing the perspective of patients was an important part of the research.MethodsThe project team included a patient collaborator with experience of presenting to the Emergency Department with sudden onset severe headache. Three additional patients were recruited to our advisory group. The patient's perspective was collected at various points through the project including at team meetings, during protocol development and when interpreting the results of the systematic review and drawing conclusions.ResultsPatients were reassured by the very high diagnostic accuracy of computed tomography (CT) for detecting SAH. Patients and clinicians emphasized the importance of shared decision making about whether to undergo additional tests to rule out SAH, after a negative CT result. When lumbar puncture was necessary, patients expressed a preference to have it on an ambulatory basis; further research on the safety and acceptability of ambulatory lumbar puncture was recommended.ConclusionsPatient input at the protocol development stage helped researchers understand the patient experience and highlighted important outcomes for assessment. Patient involvement added context to the review findings and highlighted the preferences of patients regarding the management of headache.

PP297 Management Of Sudden Onset Severe Headache Presenting To The Emergency Department: A Systematic Review

IntroductionSudden onset severe headache is usually caused by a primary headache disorder but occasionally is secondary to a more serious problem, such as subarachnoid hemorrhage (SAH). Guidelines recommend non-contrast brain computed tomography (CT) followed by lumbar puncture (LP) to exclude SAH. However, guidelines pre-date the introduction of more sensitive modern CT scanners. A systematic review was undertaken to assess the clinical effectiveness of different care pathways for the management of headache in the Emergency Department.MethodsEighteen databases (including MEDLINE and Embase) were searched to February 2020. Studies were quality assessed using criteria relevant to the study design; most studies were assessed using the QUADAS-2 tool for diagnostic accuracy studies. Where sufficient information was reported, diagnostic accuracy data were extracted into 2 × 2 tables to calculate sensitivity, specificity, false-positive and false-negative rates. Where possible, hierarchical bivariate meta-analysis was used to synthesize results, otherwise studies were synthesized narratively.ResultsFifty-one studies were included in the review. Eight studies assessing the accuracy of the Ottawa SAH clinical decision rule were pooled; sensitivity was 99.5 percent, specificity was 23.7 percent. The high false positive rate suggests that 76.3 percent SAH-negative patients would undergo further investigation unnecessarily. Four studies assessing the accuracy of CT within six hours of headache onset were pooled; sensitivity was 98.7 percent, specificity was 100 percent. CT sensitivity beyond six hours was considerably lower (≤90%; 2 studies). Three studies assessing LP following negative CT were pooled; sensitivity was 100 percent, specificity was 95.2 percent. LP-related adverse events were reported in 5.3–9.5 percent of patients.ConclusionsThe evidence suggests that the Ottawa SAH Rule is not sufficiently accurate for ruling out SAH and does little to aid clinical decision making. Modern CT within six hours of headache onset (with images assessed by a neuroradiologist) is highly accurate, but sensitivity reduces considerably over time. The CT-LP pathway is highly sensitive for detecting SAH, although LP resulted in some false-positives and adverse events.

Subarachnoid Hemorrhage: A Case Report

We reported a case report of a 50-year-old woman with stroke hemorrhage due to subarachnoid hemorrhage with hypertensive urgency, left ventricular hypertrophy, and dyslipidemia. Subarachnoid hemorrhage indicates the presence of blood in the subarachnoid space between the pia mater and arachnoid mater which usually results from a ruptured cerebral aneurysm or arteriovenous malformation. The patient presents with decreased consciousness preceded by severe headache and projectile vomiting. In physical examination, we found hypertensive emergencies and positive meningeal signs, neck stiffness, and positive Brudzinski. CT scan shows bleeding in the pontocerebellar cistern and ventricular system. The patient was diagnosed with subarachnoid hemorrhage, intraventricular hemorrhage, and emergency hypertensive. The patient was hospitalized in the neurology ward of Ulin Hospital for 20 days with the management of antihypertensive, neuroprotectant, other symptomatic medications, and ventriculoperitoneal shunt surgery. The patient was then discharged home in a stable condition.

Third-Party Partially HLA Matched Fungus-Specific T-Cells (FSTs) Used to Treat Invasive Fungal Infection (IFI) with Scedosporium Aurantiacum after Allogeneic Hemopoietic Stem Cell Transplant (aHSCT)

Introduction Invasive fungal infection (IFI) is a potentially devastating complication after allogeneic stem cell transplantation (aHSCT). Breakthrough infections are an increasing threat. The adoptive transfer of fungus-specific T cells (FSTs), analogous to virus specific T-cells for viral reactivation, may improve clinical outcomes but the delay involved in generating FSTs from the stem cell donor is problematic for this type of adoptive cell therapy. We created a bank of FSTs from normal donors for use in patients with post-transplant IFI. Here we describe the first use of partially HLA matched 3 rd party FSTs to treat IFI in a patient after aHSCT. Methods FSTs were manufactured by stimulating G-CSF primed apheresis products overnight with monocyte derived dendritic cells pulsed with lysates from Aspergillus terreus and Candida krusei. CD137 expressing cells were isolated and cultured with CD137 negative feeders in medium supplemented with IL-2, IL-7 and IL-15 for 12 days prior to assessment of target specificity and HLA restriction. Cells consisted principally of CD4 + lymphocytes secreting TNF-α, interferon-γ and IL-17 in response to fungal antigen stimulation. Standard release criteria were applied. We commenced a phase 1 cell dose escalation trial to assess the safety and efficacy of partially HLA-DR matched 3 rd party FSTs from a cryopreserved bank in patients with proven or probable IFI after aHSCT. Results Patient A is a 27 year old female who underwent a myeloablative sibling haploidentical transplant for Philadelphia negative B-ALL in second remission. At day 100 she developed grade III lower GI GVHD requiring methylprednisolone and ruxolitinib for steroid dependent disease. Subsequent CMV reactivation was treated with ganciclovir. Cough in association with pulmonary infiltrates followed, and a bronchoalveolar lavage grew Scedosporium aurantiacum, Clavispora lusitaniaand Aspergillus fumigatus. She developed severe headache and MRI imaging showed a thin rim-enhancing 38x37 mm lesion within the right frontal lobe with moderate vasogenic oedema. Surgical drainage yielded 20 ml of frank pus that grew Scedosporium aurantiacum. Antifungal therapy was started with vorinconazole, terbinafine, amphotericin and later caspofungin. Serial imaging after 12 days showed two new hyperdense foci representing extension of infection, consistent with worsening headaches. The patient received a single infusion of 3 rd party FSTs at a dose of 1 x10 6/m 2 at day 170 post-transplant while continuing antifungal therapy with vorinconazole and terbinafine. The product consisted of 94.1% CD4 +, 3.5% CD8 + T-cells and 1% NK cells and contained CD4 + T-cells responsive to both A. terreus and C. krusei antigens presented by HLA DR*03:01 shared between product and patient. There were no infusion related adverse events. Corticosteroids and calcineurin inhibitors were continued. Within one week of FST infusion there was an increase in the number of naïve and central memory CD4 + T-cells in blood and a fall in the number of CD4 + and CD8 + T-cells expressing Tim3. Over the following 3 months, there was a gradual rise in the number of CD4 + Tem and CD4 + Temra with a later and less pronounced rise in the analogous CD8 + populations. Serial imaging demonstrated rapid regression of the pulmonary abnormalities and gradual regression of the cerebral lesion at day 150 following FST infusion. 279 days after transplant and 109 days after infusion of FSTs, the patient developed worsening of headache and MRI confirmed rupture of the abscess into the right ventricle. Headache gradually resolved and the patient was discharged from hospital 329 days after transplant with ECOG 1 and no neurological abnormalities. However she was readmitted 13 days later with more severe headache with repeat imaging confirming raised intracranial pressure. CSF showed no evidence of fungi by PCR or culture. A CSF shunt was inserted and the patient remains well. Conclusion We report the first infusion of 3 rd party partially HLA DR matched fungus-specific T-cells for disseminated fungal infection following allogeneic stem cell transplantation. These data demonstrate the feasibility of this approach. The patient's favourable clinical outcome and phenotyping results suggest that the initial cell dose level is safe and may be associated with immune alterations that promote anti-fungal activity. Further trial recruitment is ongoing. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

A Man With Recurrent Headache and Focal Neurologic Deficits

A 42-year-old healthy man sought care for transient episodes of neurologic deficits followed by severe headache. The first episode began with left hand weakness, numbness, and dysarthria, followed approximately 1 hour later by a right temporal headache. His symptoms spontaneously resolved after 8 hours. He had a second episode 2 days later manifested by confusion and bilateral lower extremity numbness, again followed by severe headache with symptoms resolving within 12 hours. A total of 8 episodes occurred over 3 weeks, each lasting 8 to 24 hours, with spontaneous resolution each time. His most recent episode occurred during cerebral angiography. Cerebrospinal fluid evaluation showed opening pressure, 190 mm H2O; white blood cells, 205/μ‎L, 97% lymphocytes; protein, 95 mg/dL; and glucose, 40 mg/dL. Electroencephalography demonstrated right greater than left generalized slowing, with increased-voltage rhythmic delta wave activity, in the frontal regions predominantly. Conventional cerebral angiography findings were normal, but the test appeared to provoke the patient’s previous episode. Neurologic examination was normal after his most recent episode resolved, and no further episodes were reported. This case highlights a typical presentation of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis. Because the disorder was self-limited, treatment was aimed at symptomatic management of headache. In this case patient with a secure diagnosis of headache and neurologic deficits with cerebrospinal fluid lymphocytosis and stereotypical episodes limited to 3 months after the initial presentation, additional testing was not indicated. Headache and neurologic deficits with cerebrospinal fluid lymphocytosis is a rare, self-limited, benign condition with migrainelike headache episodes accompanied by transient neurologic deficits usually lasting more than 4 hours, with some deficits lasting more than 24 hours.