1. 2010 Midwest Pediatric Hospital Medicine Conference
Clinical conundrum
2010 Midwest Pediatric Hospital Medicine Conference
June 12, 2010
Matthew Johnson, MD

2. Chief complaint
6 month old hispanic male with fever for 12 days and intermittent use of right arm

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

4. HPI – cont’d 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

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

6. Medications
Acetaminophen 80mg prn fever
Ibuprofen 80mg prn fever

7. Allergies
No allergies or adverse reactions to any medications or foods

8. Immunizations
Received 2 month immunizations, but not 4 or 6 month immunizations

9. Family History
Non-contributory

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

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

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.

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.

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.

15. Differential Diagnosis

16. Labs/Studies CBC BMP Urinalysis Liver Function Tests
Inflammatory Markers
Body Fluid Analysis
Pathology
Microbiology
CXR
CT Scan
MRI
2-D Echo
Other Studies
Other Imaging
Clinical Course

17. CBC
9.2
20.3
1,189
27.2
Neut 52, Lymph 38, Mono 8
MCV 77

18. BMP
133
102 5 88 22
0.5
4.8
Ca 9.2 ( )

19. Urine Analysis Sp. G. > 1.030 pH 7.5 Blood negative
Ketones negative
Glu negative
Prot 1+
LE negative
Urobil negative
Bili negative
Micro – no RBC, no WBC

20. Liver Function Tests AST 48 (20-50) ALT 63 (20-50)
Alk. Phos 102 (40-125)
Bilirubin 0.2 (0-1.1)
Total protein 6.6 ( )
Albumin 3.6 ( )

21. Inflammatory Markers
CRP – 1.3
ESR – 83

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

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

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

25. CXR
IMPRESSION: Peribronchial thickening consistent with bronchiolitis or reactive airways disease. No evidence of focal pneumonia.

26. CT Scan

27. CT Scan

28. CT 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 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.

29. MRI

30. MRI

31. MRI
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.

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

33. Other Imaging Right shoulder film – 2 view no fracture or dislocation
Cervical spine film – 2 view
normal C-spine

34. Other Studies LDH – 713 Uric Acid – 2.0
Culture from spinal abscess – methicillin sensitive Staph aureus

35. Diagnosis
Thoracic (T2) osteomyelitis, discitis, and spinal abscess secondary to MSSA

36. Clinical Course
Started on ceftriaxone at meningitic doses pending CSF cultures
Seemed to improve
Infectious diseases consulted, concern for Kawasaki’s
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