Presentation on theme: "2010 Midwest Pediatric Hospital Medicine Conference"— Presentation transcript:
1 2010 Midwest Pediatric Hospital Medicine Conference Clinical conundrum2010 Midwest Pediatric Hospital Medicine ConferenceJune 12, 2010Matthew Johnson, MD
2 Chief complaint6 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/ibuprofenFussy, not wanting to be heldIntermittently refusing to use right armPain with movement of neck
4 HPI – cont’d Not rolling over anymore or scooting/crawling Some intermittent rash to lower extremitiesSeen in UCC/ED/PCP x 4, CXR and labwork unremarkableRight arm/shoulder films negativeAdmitted from ED following LP
5 Past Medical History Born full term by SVD Birth weight 9#1oz Mother positive for GBBS, treated with antibioticsNo subsequent hospitalizations, surgeries, or chronic illnesses
10 Social History Patient lives with parents, 2 sisters, and 2 brothers Exposed to dogsNo day careMom from Puerto Rico, Dad from NicaraguaBoth parents in US since childhoodPatient has never left Kansas CityNo recent foreign visitors
11 Review of SystemsHEENT – intermittent eye redness, no drainage, no congestion, no tongue or lip changesPulmonary – no cough, no wheezingCV – negativeGI – decreased po intake, no vomiting or diarrhea, some gasGU – normal uopBone/Skin/Joint – intermittent rash to lower extremities, no hand or feet swellingNeurologic – 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 ExamNEURO: 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.
23 PathologyA. 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
28 CT ScanPermeative 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.
31 MRI1. 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 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
33 Other Imaging Right shoulder film – 2 view no fracture or dislocation Cervical spine film – 2 viewnormal C-spine
34 Other Studies LDH – 713 Uric Acid – 2.0 Culture from spinal abscess – methicillin sensitive Staph aureus
35 DiagnosisThoracic (T2) osteomyelitis, discitis, and spinal abscess secondary to MSSA
36 Clinical CourseStarted on ceftriaxone at meningitic doses pending CSF culturesSeemed to improveInfectious diseases consulted, concern for Kawasaki’sTreated with IVIG and started on aspirinFollowing MRI findings, vancomycin was addedNeurosurgery consulted and underwent laminectomy and spinal abscess drainageTolerated very well, cultures grew MSSATreated with IV antibiotics for 10 days, oral linezolid for 14 days, and oral cephalexin to complete 6 week course