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