Friday, September 28, 2018, 7:30-10:10 h: Poster Session – 01: Headache and Dementia

Background: Only high suspicion index can help in the correct diagnosis of some secondary headaches. We present an unusual case of secondary headache in a young patient.

Case Report: An 18-year-old female presented with low-grade fever, decreased appetite and migrainous headaches especially during early morning for 2 months. She had transient visual obscurations and double vision. Examination revealed significant pallor, bilateral Grade IV papilledema with superficial retinal hemorrhages, bilateral lateral rectus palsy, and positive Kernig's. Her noncontrast computed tomography of the head was normal. CECT revealed basal exudates without any other abnormality. A possibility of chronic meningitis with secondary headache was considered. However, the cerebrospinal fluid tap was hemorrhagic. Further investigations showed pancytopenia with Hb-6 g/dl, TLC-2800/cumm, platelet count-10000/cumm, and ESR-85 mm/h. Corrected reticulocyte count was 1.3% and coombs was negative. ATT and oral steroids were started empirically. The patient became a febrile with better appetite but pancytopenia persisted. Bone marrow aspiration revealed hypocellular marrow with normal cells. Contrast-enhanced magnetic resonance imaging of the brain showed multiple subdural bleeds with diffuse pachymeningeal enhancement and normal magnetic resonance angiography and magnetic resonance venography. In view of persistent pancytopenia, her autoimmune profile was done. She was positive for ANA (3+, speckled pattern), ds-DNA and U1-SnRP. Antiphospholipid antibodies and proteinuria were negative. ATT was stopped and pulse methyl-prednisolone for 5 days followed by oral steroids was given. She became asymptomatic with complete reversal of pancytopenia. The final diagnosis of systemic lupus erythematosus (SLICC criteria) presenting as headache, fever, and pancytopenia was made. At 3 months follow-up, she remains asymptomatic on low dose of steroids.

Conclusion: SLE is a great masquerader which occasionally can present only as headache and pancytopenia.