Abstract Details

Title New-onset TAC Following a Trip to New Mexico: An Initial Presentation of CLL with CNS Involvement

Topic Headache

Presentation(s) P2 - Poster Session 2 (11:45 AM-12:45 PM)

Poster/Presentation
Number 15-014

Objective Explore diagnostic clues in a case of secondary headache mimicking trigeminal autonomic cephalalgia, ultimately diagnosed as secondary to B-cell lymphoproliferative disease.

Background Trigeminal autonomic cephalalgias (TACs) are characterized by unilateral, severe headaches with ipsilateral cranial autonomic features. Though most are primary, secondary causes must be considered in patients with atypical features, abnormal exams, or poor response to therapies.

Design/Methods NA

Results A 47-year-old previously healthy male developed new-onset headaches and upper respiratory symptoms after a week of travel to New Mexico, where he spent time in straw bale homes and participated in banjo camp. One week after return, he presented to an emergency department for headaches. Head CT/CTA noted mildly prominent nonspecific lymph nodes. One month into symptoms, he presented outpatient to neurologist describing severe, non-positional, stabbing, left-sided headache with conjunctival injection, congestion, and lacrimation lasting hours with minimal relief between episodes. TAC was considered, however both indomethacin and sumatriptan were ineffective. Notably, serial courses of prednisone provided excellent transient relief. Two months into his course, headaches worsened in duration and severity prompting him to seek care in our emergency department. A secondary cause was suspected, with fungal (given travel history) and neoplastic causes of greatest concern after fundus photography demonstrated bilateral papilledema. He was admitted to Neurology, and CSF analysis revealed a clonal B-cell population consistent with chronic lymphocytic leukemia. He was transferred to Oncology for staging and initiation of Rituximab.

Conclusions Secondary causes of TAC should be considered in patients with red flag features or exam findings. Atypical symptoms in this patient’s case included travel history, rapid escalation of symptoms, exquisite symptomatic response to steroids, and poor response to standard therapies. Atypical signs included papilledema and persistent lymphadenopathy. Secondary headaches can mimic primary forms but may be associated with underlying malignancy, infection, or inflammatory disease; recognition and targeted diagnostic workup are critical.

Authors/Disclosures
Jenna L. Miller, MD PRESENTER	Dr. Miller has nothing to disclose.
Aaron M. Carlson, MD (University of Colorado, School of Medicine, Department of Neurology)	Dr. Carlson has received research support from Horizon Therapeutics (Amgen).

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