Presentation on theme: "Clinical conundrum 2010 Midwest Pediatric Hospital Medicine Conference June 12, 2010 Matthew Johnson, MD."— Presentation transcript:
Clinical conundrum 2010 Midwest Pediatric Hospital Medicine Conference June 12, 2010 Matthew Johnson, MD
Chief complaint 6 month old hispanic male with fever for 12 days and intermittent use of right arm
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
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
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
Allergies No allergies or adverse reactions to any medications or foods
Immunizations Received 2 month immunizations, but not 4 or 6 month immunizations
Family History Non-contributory
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
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
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.
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.
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.
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
CBC ,189 Neut 52, Lymph 38, Mono 8 MCV 77
BMP Ca 9.2 ( )
Urine Analysis Sp. G. > pH7.5 Bloodnegative Ketonesnegative Glunegative Prot1+ LEnegative Urobilnegative Bilinegative Micro – no RBC, no WBC
Liver Function Tests AST48 (20-50) ALT63 (20-50) Alk. Phos102 (40-125) Bilirubin0.2 (0-1.1) Total protein6.6 ( ) Albumin3.6 ( )
Inflammatory Markers CRP – 1.3 ESR – 83
Body Fluid Analysis CSF RBC 534 WBC 27 (6 seg, 10 lymph, 84 mono) Glucose 46 Protein 114 Gram stain – no organisms, moderate WBC
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
CXR IMPRESSION: Peribronchial thickening consistent with bronchiolitis or reactive airways disease. No evidence of focal pneumonia.
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.
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.
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
Other Imaging Right shoulder film – 2 view no fracture or dislocation Cervical spine film – 2 view normal C-spine
Diagnosis Thoracic (T2) osteomyelitis, discitis, and spinal abscess secondary to MSSA Thoracic (T2) osteomyelitis, discitis, and spinal abscess secondary to MSSA
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