Iverson, Olivia C

Objectives: Identify the frequency of abnormal neurological examinations among patients presenting in person for headache consultation. Determine what proportion of patients with abnormal examinations have accompanying red flags in their histories and/or undergo diagnostic workup. Methods: We conducted a retrospective review of patients presenting in person for headache consultation at a tertiary/quaternary headache clinic between June 2022 and May 2023. We excluded examination abnormalities consistent with known comorbidity, functional neurological disorder, and/or non-headache disease. We then calculated the proportion of patients with an abnormal neurological examination. For patients with abnormal examinations, the electronic medical record was further reviewed for red-flag components in the history, diagnostic workup ordered, and the resulting diagnosis. Results: Of 1281 patients presenting for in-person headache consultation, 218 (17%) had abnormal neurological examinations that were not consistent with known comorbidity, functional neurological disorder, or non-headache disease. Of these, 203 (93%) had a red flag in their history. The remaining 15 patients with abnormal examinations and no historical red flags comprised 1.2% of all 1281 patients. Regarding workup, 160 (73%) had neuro-imaging and 61 (28%) had laboratory studies ordered and/or requested for review, of which 13% and 8% were concerning for pathology, respectively. Conclusions: A small but notable proportion of patients presenting for in-person headache consultation had abnormalities on neurological examination. The majority of these patients received imaging, with a diagnostic yield higher than previously reported. However, the vast majority of patients with abnormal examinations also had red flags in their history to prompt diagnostic workup.

ABSTRACTBackgroundDrug‐induced hypersensitivity syndrome (DiHS), or drug reaction with eosinophilia and systemic symptoms (DRESS), is a delayed and severe immune response to certain medications. We investigated vancomycin‐induced DiHS/DRESS, notable for frequent and severe organ involvement, to describe its specific histopathology and the correlations between histopathologic and clinical findings.MethodsA retrospective review was conducted to identify patients between 2006 and 2022 who received vancomycin, had archived skin biopsy specimens, and were scored as having probable or definite DiHS/DRESS. Clinical features were retrospectively collected, and biopsy specimens were reviewed by a board‐certified dermatopathologist. A subset of histopathologic and clinical features was analyzed for statistical correlation.ResultsTwenty‐three patients met the inclusion criteria. Most biopsy specimens (87%) showed an eczematous reaction pattern; 17 (74%) showed a secondary reaction pattern. Spongiosis (87%) and neutrophilic infiltration (91%) were common epidermal characteristics. The dermal inflammatory infiltrate was frequently superficial (87%) and consistently included plasma cells (96%). Eosinophils were present in the dermis in 70% of cases. Parakeratosis negatively correlated with liver involvement and positively correlated with desquamative rash. Epidermal lymphocytes were negatively correlated with the RegiSCAR score.ConclusionsVancomycin‐associated DiHS/DRESS histopathology was characterized by a frequent eczematous reaction pattern, multiple coexisting reaction patterns, and epidermal neutrophilic infiltration.