Clinical conundrum
Clinical conundrum2010 Midwest Pediatric 2010 Midwest Pediatric
Hospital Medicine Hospital Medicine ConferenceConference
June 12, 2010June 12, 2010
Matthew Johnson, MDMatthew Johnson, MD
Chief complaintChief complaint
6 month old hispanic male with 6 month old hispanic male with fever for 12 days and fever for 12 days and
intermittent use of right arm intermittent use of right arm
HPIHPI
Fever as high as 105 daily x12 days, Fever as high as 105 daily x12 days, average 103, no patternaverage 103, no pattern
Defervesces briefly with Defervesces briefly with acetaminophen/ibuprofenacetaminophen/ibuprofen
Fussy, not wanting to be heldFussy, not wanting to be held Intermittently refusing to use right Intermittently refusing to use right
armarm Pain with movement of neckPain with movement of neck
HPI – cont’dHPI – cont’d
Not rolling over anymore or Not rolling over anymore or scooting/crawlingscooting/crawling
Some intermittent rash to lower Some intermittent rash to lower extremitiesextremities
Seen in UCC/ED/PCP x 4, CXR and Seen in UCC/ED/PCP x 4, CXR and labwork unremarkablelabwork unremarkable
Right arm/shoulder films negativeRight arm/shoulder films negative Admitted from ED following LPAdmitted from ED following LP
Past Medical HistoryPast Medical History
Born full term by SVDBorn full term by SVD Birth weight 9#1ozBirth weight 9#1oz Mother positive for GBBS, Mother positive for GBBS,
treated with antibioticstreated with antibiotics No subsequent hospitalizations, No subsequent hospitalizations,
surgeries, or chronic illnessessurgeries, or chronic illnesses
MedicationsMedications
Acetaminophen 80mg prn feverAcetaminophen 80mg prn fever Ibuprofen 80mg prn feverIbuprofen 80mg prn fever
AllergiesAllergies
No allergies or adverse No allergies or adverse reactions to any medications or reactions to any medications or foodsfoods
ImmunizationsImmunizations
Received 2 month Received 2 month immunizations, but not 4 or 6 immunizations, but not 4 or 6 month immunizationsmonth immunizations
Family HistoryFamily History
Non-contributoryNon-contributory
Social HistorySocial History
Patient lives with parents, 2 sisters, Patient lives with parents, 2 sisters, and 2 brothersand 2 brothers
Exposed to dogsExposed to dogs No day careNo day care Mom from Puerto Rico, Dad from Mom from Puerto Rico, Dad from
NicaraguaNicaragua Both parents in US since childhoodBoth parents in US since childhood Patient has never left Kansas CityPatient has never left Kansas City No recent foreign visitorsNo recent foreign visitors
Review of SystemsReview of Systems
HEENT – HEENT – intermittent eye rednessintermittent eye redness, no drainage, , no drainage, no congestion, no tongue or lip changesno congestion, no tongue or lip changes
Pulmonary – no cough, no wheezingPulmonary – no cough, no wheezing CV – negativeCV – negative GI – GI – decreased po intakedecreased po intake, no vomiting or , no vomiting or
diarrhea, some gasdiarrhea, some gas GU – normal uopGU – normal uop Bone/Skin/Joint – Bone/Skin/Joint – intermittent rash to lower intermittent rash to lower
extremitiesextremities, no hand or feet swelling, no hand or feet swelling Neurologic – Neurologic – irritable, cries when held, ? Loss irritable, cries when held, ? Loss
of milestonesof milestones
Physical ExamPhysical Exam VS: T 37.3 HR 149 R 45 BP 124/81 VS: T 37.3 HR 149 R 45 BP 124/81 WT 8.7 KG WT 8.7 KG GEN: awake, alert and NAD. Not ill or toxic GEN: awake, alert and NAD. Not ill or toxic
appearing. appearing. HEAD/NECK: AFSF. NCAT. Supple. Passive ROM HEAD/NECK: AFSF. NCAT. Supple. Passive ROM
is normal. Neck is nontender. is normal. Neck is nontender. EYES: PERRL. EOMI. No eye discharge or EYES: PERRL. EOMI. No eye discharge or
erythema.erythema. ENT: TMs and pharynx are clear. No pharyngeal ENT: TMs and pharynx are clear. No pharyngeal
asymmetry. MMM. No nasal flaring or discharge.asymmetry. MMM. No nasal flaring or discharge. CHEST: clear and without retractions.CHEST: clear and without retractions. CV: RRR and no murmur. Brisk CR.CV: RRR and no murmur. Brisk CR.
Physical ExamPhysical Exam
ABD: soft, NT, ND. No HSM or masses ABD: soft, NT, ND. No HSM or masses appreciated.appreciated.
GU: normal male with bilaterally descended GU: normal male with bilaterally descended testicles.testicles.
LYMPH: no adenopathy.LYMPH: no adenopathy. EXT: warm, pink and well perfused. No point EXT: warm, pink and well perfused. No point
tenderness of the spinal processes, tenderness of the spinal processes, extremities, clavicles, or joints. No joint edema extremities, clavicles, or joints. No joint edema or erythema. or erythema.
Physical ExamPhysical Exam
NEURO: Normal mental status for age. Normal NEURO: Normal mental status for age. Normal muscle tone and strength for age.muscle tone and strength for age.
Ability to sit is appropriate for age. Able to bear Ability to sit is appropriate for age. Able to bear weight with his legs with assistance. weight with his legs with assistance. Spontaneous movement of all extremities. Spontaneous movement of all extremities.
SKIN: SKIN: mild, faint erythematous macular rash on mild, faint erythematous macular rash on the anterior thighs with R greater than leftthe anterior thighs with R greater than left. No . No petechiae or vesicular lesions.petechiae or vesicular lesions.
Differential DiagnosisDifferential Diagnosis
Labs/StudiesLabs/Studies
CBCBMPUrinalysisLiver Function Tests Inflammatory MarkersBody Fluid AnalysisPathology
MicrobiologyCXRCT ScanMRI2-D EchoOther Studies Other Imaging
Clinical CourseClinical Course
CBCCBC
20.39.2
27.21,189
Neut 52, Lymph 38, Mono 8
MCV 77
BMPBMP
133
4.8
102
22
5
0.588
Ca 9.2 (8.8-10.5)
Urine AnalysisUrine Analysis
Sp. G.Sp. G. > 1.030 > 1.030
pHpH 7.57.5
BloodBlood negativenegative
KetonesKetones negativenegative
GluGlu negativenegative
ProtProt 1+1+
LELE negativenegative
UrobilUrobil negativenegative
BiliBili negativenegative
Micro – no RBC, no Micro – no RBC, no WBCWBC
Liver Function TestsLiver Function Tests
ASTAST 48 (20-50)48 (20-50)
ALTALT 63 (20-50)63 (20-50)
Alk. PhosAlk. Phos 102 (40-125)102 (40-125)
BilirubinBilirubin 0.2 (0-1.1)0.2 (0-1.1)
Total proteinTotal protein 6.6 (6.2-8.3)6.6 (6.2-8.3)
AlbuminAlbumin 3.6 (3.6-4.6)3.6 (3.6-4.6)
Inflammatory MarkersInflammatory Markers
CRP – 1.3CRP – 1.3
ESR – 83 ESR – 83
Body Fluid AnalysisBody Fluid Analysis
CSF CSF
RBC 534RBC 534
WBC 27WBC 27
(6 seg, 10 lymph, 84 mono)(6 seg, 10 lymph, 84 mono)
Glucose 46Glucose 46
Protein 114Protein 114
Gram stain – no organisms, moderate WBCGram stain – no organisms, moderate WBC
PathologyPathology
A. Spinal cord, dura and soft epidural tissue, T2 A. Spinal cord, dura and soft epidural tissue, T2 level, biopsy:level, biopsy:
MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC INFILTRATES CONSISTENT WITH INFECTION/ INFILTRATES CONSISTENT WITH INFECTION/ EPIDURAL ABSCESS AS DESCRIBED. EPIDURAL ABSCESS AS DESCRIBED.
B. Spinal cord, dura and soft epidural tissue, T2 B. Spinal cord, dura and soft epidural tissue, T2 level, biopsy:level, biopsy:
MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC INFILTRATES CONSISTENT WITH INFECTION/ INFILTRATES CONSISTENT WITH INFECTION/ EPIDURAL ABSCESS AS DESCRIBEDEPIDURAL ABSCESS AS DESCRIBED
MicrobiologyMicrobiology
Blood culture negativeBlood culture negative Urine culture negativeUrine culture negative CSF culture negativeCSF culture negative CSF enterovirus PCR negativeCSF enterovirus PCR negative EBV titers negativeEBV titers negative CMV titers negativeCMV titers negative Viral Respiratory PCR negativeViral Respiratory PCR negative PPD negativePPD negative
CXRCXR
IMPRESSION: Peribronchial thickening IMPRESSION: Peribronchial thickening consistent with bronchiolitis or reactive consistent with bronchiolitis or reactive airways disease. No evidence of focal airways disease. No evidence of focal pneumonia.pneumonia.
CT ScanCT Scan
CT ScanCT Scan
CT ScanCT Scan
Permeative and destructive appearance involving the T2 vertebral body with associated paraspinal phlegmon and intraspinal phlegmon which is producing effacement of the spinal cord. There areareas within the intraspinal phlegmon which are suggestive of abscess formation. An MRI with contrast and diffusion weighted imaging is recommended for further evaluation.
MRIMRI
MRIMRI
MRIMRI1. Imaging findings consistent with vertebral osteomyelitis centered at the T2 vertebral level but with abnormal marrow signal and enhancement extending from T2-T4.2. Complicating epidural abscess formation with displacement of the spinal cord left of midline. The spinal canal is compromised by approximately 50% at the T2 vertebral level. No large paraspinous soft tissue abnormality identified.3. While findings may relate to bacterial osteomyelitis, granulomatous disease/tuberculosis should also be in the differential considerations.
2-D Echocardiogram2-D Echocardiogram1. Possible mildly ectatic left main coronary artery.2. Normal-appearing right coronary artery.3. Normal LV dimensions and systolic function.4. No mitral or aortic valve regurgitation.5. No pericardial effusion.6. Recommend sedated study for better evaluation of coronary arteries if Kawasaki's is a clinical concern.
Sedated echo – normal coronary arteries
Other ImagingOther Imaging
Right shoulder film – 2 view no fracture or dislocation
Cervical spine film – 2 viewnormal C-spine
Other StudiesOther Studies
LDH – 713LDH – 713 Uric Acid – 2.0Uric Acid – 2.0 Culture from spinal abscess – Culture from spinal abscess –
methicillin sensitive Staph methicillin sensitive Staph aureusaureus
DiagnosisDiagnosis
Thoracic (T2) osteomyelitis, Thoracic (T2) osteomyelitis, discitis, and spinal abscess discitis, and spinal abscess
secondary to MSSAsecondary to MSSA
Clinical CourseClinical Course
Started on ceftriaxone at meningitic doses pending Started on ceftriaxone at meningitic doses pending CSF culturesCSF cultures
Seemed to improveSeemed to improve Infectious diseases consulted, concern for Infectious diseases consulted, concern for
Kawasaki’sKawasaki’s Treated with IVIG and started on aspirinTreated with IVIG and started on aspirin Following MRI findings, vancomycin was addedFollowing MRI findings, vancomycin was added Neurosurgery consulted and underwent laminectomy Neurosurgery consulted and underwent laminectomy
and spinal abscess drainageand spinal abscess drainage Tolerated very well, cultures grew MSSATolerated very well, cultures grew MSSA Treated with IV antibiotics for 10 days, oral linezolid Treated with IV antibiotics for 10 days, oral linezolid
for 14 days, and oral cephalexin to complete 6 week for 14 days, and oral cephalexin to complete 6 week coursecourse
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