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Clinical conundrum 2010 Midwest Pediatric Hospital Medicine Conference June 12, 2010 Matthew Johnson, MD Slide 2 Chief complaint 6 month old hispanic male with fever for 12 days and intermittent use of right arm Slide 3 HPI Fever as high as 105 daily x12 days, average 103, no pattern Defervesces briefly with acetaminophen/ibuprofen Fussy, not wanting to be held Intermittently refusing to use right arm Pain with movement of neck Slide 4 HPI contd Not rolling over anymore or scooting/crawling Some intermittent rash to lower extremities Seen in UCC/ED/PCP x 4, CXR and labwork unremarkable Right arm/shoulder films negative Admitted from ED following LP Slide 5 Past Medical History Born full term by SVD Birth weight 9#1oz Mother positive for GBBS, treated with antibiotics No subsequent hospitalizations, surgeries, or chronic illnesses Slide 6 Medications Acetaminophen 80mg prn fever Ibuprofen 80mg prn fever Slide 7 Allergies No allergies or adverse reactions to any medications or foods Slide 8 Immunizations Received 2 month immunizations, but not 4 or 6 month immunizations Slide 9 Family History Non-contributory Slide 10 Social History Patient lives with parents, 2 sisters, and 2 brothers Exposed to dogs No day care Mom from Puerto Rico, Dad from Nicaragua Both parents in US since childhood Patient has never left Kansas City No recent foreign visitors Slide 11 Review of Systems HEENT intermittent eye redness, no drainage, no congestion, no tongue or lip changes Pulmonary no cough, no wheezing CV negative GI decreased po intake, no vomiting or diarrhea, some gas GU normal uop Bone/Skin/Joint intermittent rash to lower extremities, no hand or feet swelling Neurologic irritable, cries when held, ? Loss of milestones Slide 12 Physical Exam VS: T 37.3 HR 149 R 45 BP 124/81 WT 8.7 KG GEN: awake, alert and NAD. Not ill or toxic appearing. HEAD/NECK: AFSF. NCAT. Supple. Passive ROM is normal. Neck is nontender. EYES: PERRL. EOMI. No eye discharge or erythema. ENT: TMs and pharynx are clear. No pharyngeal asymmetry. MMM. No nasal flaring or discharge. CHEST: clear and without retractions. CV: RRR and no murmur. Brisk CR. Slide 13 Physical Exam ABD: soft, NT, ND. No HSM or masses appreciated. GU: normal male with bilaterally descended testicles. LYMPH: no adenopathy. EXT: warm, pink and well perfused. No point tenderness of the spinal processes, extremities, clavicles, or joints. No joint edema or erythema. Slide 14 Physical Exam NEURO: Normal mental status for age. Normal muscle tone and strength for age. Ability to sit is appropriate for age. Able to bear weight with his legs with assistance. Spontaneous movement of all extremities. SKIN: mild, faint erythematous macular rash on the anterior thighs with R greater than left. No petechiae or vesicular lesions. Slide 15 Differential Diagnosis Slide 16 Labs/Studies CBC BMP Urinalysis Liver Function Tests Liver Function Tests Inflammatory Markers Inflammatory Markers Body Fluid Analysis Body Fluid Analysis Pathology Microbiology CXR CT Scan CT Scan MRI 2-D Echo 2-D Echo Other Studies Other Studies Other Imaging Other Imaging Clinical Course Clinical Course Slide 17 CBC 20.3 9.2 27.2 1,189 Neut 52, Lymph 38, Mono 8 MCV 77 Slide 18 BMP 133 4.8 102 22 5 0.5 88 Ca 9.2 (8.8-10.5) Slide 19 Urine Analysis Sp. G. > 1.030 pH7.5 Bloodnegative Ketonesnegative Glunegative Prot1+ LEnegative Urobilnegative Bilinegative Micro no RBC, no WBC Slide 20 Liver Function Tests AST48 (20-50) ALT63 (20-50) Alk. Phos102 (40-125) Bilirubin0.2 (0-1.1) Total protein6.6 (6.2-8.3) Albumin3.6 (3.6-4.6) Slide 21 Inflammatory Markers CRP 1.3 ESR 83 Slide 22 Body Fluid Analysis CSF RBC 534 WBC 27 (6 seg, 10 lymph, 84 mono) Glucose 46 Protein 114 Gram stain no organisms, moderate WBC Slide 23 Pathology A. Spinal cord, dura and soft epidural tissue, T2 level, biopsy: MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC INFILTRATES CONSISTENT WITH INFECTION/ EPIDURAL ABSCESS AS DESCRIBED. B. Spinal cord, dura and soft epidural tissue, T2 level, biopsy: MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC INFILTRATES CONSISTENT WITH INFECTION/ EPIDURAL ABSCESS AS DESCRIBED Slide 24 Microbiology Blood culture negative Urine culture negative CSF culture negative CSF enterovirus PCR negative EBV titers negative CMV titers negative Viral Respiratory PCR negative PPD negative Slide 25 CXR IMPRESSION: Peribronchial thickening consistent with bronchiolitis or reactive airways disease. No evidence of focal pneumonia. Slide 26 CT Scan Slide 27 Slide 28 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 are areas within the intraspinal phlegmon which are suggestive of abscess formation. An MRI with contrast and diffusion weighted imaging is recommended for further evaluation. Slide 29 MRI Slide 30 Slide 31 1. 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. Slide 32 2-D Echocardiogram 1. 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 Slide 33 Other Imaging Right shoulder film 2 view no fracture or dislocation Cervical spine film 2 view normal C-spine Slide 34 Other Studies LDH 713 Uric Acid 2.0 Culture from spinal abscess methicillin sensitive Staph aureus Slide 35 Diagnosis Thoracic (T2) osteomyelitis, discitis, and spinal abscess secondary to MSSA Thoracic (T2) osteomyelitis, discitis, and spinal abscess secondary to MSSA Slide 36 Clinical Course Started on ceftriaxone at meningitic doses pending CSF cultures Seemed to improve Infectious diseases consulted, concern for Kawasakis Treated with IVIG and started on aspirin Following MRI findings, vancomycin was added Neurosurgery consulted and underwent laminectomy and spinal abscess drainage Tolerated very well, cultures grew MSSA Treated with IV antibiotics for 10 days, oral linezolid for 14 days, and oral cephalexin to complete 6 week course Slide 37