Hot Seat Case #101: 17 yo male with lower back pain
Posted on: October 23, 2017, by : Nadira Ramkhelawan
Nadira Ramkhelawan MD, INOVA Fairfax Children’s Hospital
with Joelle Simpson MD Children’s National Medical Center
The Case
A 17 year old healthy male came in to the ED complaining of lower back pain for the past 6 weeks. He stated it began after tubing down a nearby river 6 weeks ago of which he complained of diffuse soreness the following day. 5 weeks ago he reported weekly fevers that have increased in frequency over the last 1.5 weeks to daily. In the interim he was seen by orthopedics, physical therapy, and one visit to the emergency department. He was advised supportive care including stretching exercises and oxycodone as needed.
ROS: Decreased PO, no vomiting, no diarrhea, no rashes. currently denies paresthesias but states he has intermittent numbness from his thighs to above his knees bilaterally. no urinary or bowel incontinence. +12 lb weight loss in the last 2 weeks.
PMH: None
PSH: None
PE: T 101.2 °C, HR 105, BP 125/74, RR20, SpO2 97 % on RA, Wt 54.9kg
General: Unwell appearing, Painful distress (currently 7/10)
HEENT: NC/AT, AFOF, moist mucous membranes, oropharynx nonerythematous with no lesions.
CV: Tachycardic, regular rhythm, no murmurs or rubs. Cap refill <3secs.
Pulm: Good air entry bilaterally, no wheezing or crackles. No retractions
Abd: +BS, soft, NTND, no HSM
Neuro: Awake and alert, CN 2-12 intact, strength 5/5 in bilateral upper and lower extremities. Sensation intact and equal in bilateral lower extremities. No cerebellar signs. Normal gait.
MSK: mild tenderness of lumbar spine, no erythema, swelling, or bony abnormalities of spine. Mild pain on hip rotation, extreme flexion, and extension. No effusion or tenderness to palpation of bilateral hip joints.
He reported 7/10 lumbar pain and last took his oxycodone 5 hours prior to arrival.
CBC with differential was normal. However, CRP was elevated to 19 and ESR to 68.
Blood culture was sent and pending. He was given a dose of morphine for pain control. Reassessment of his pain score was a 3/10.
Repeat VS: T 99.4 °C, HR 91, BP 122/73, RR20, SpO2 98 % on RA
You would like to obtain an MRI, however, are unable to from the ED. Upon discussion with the family you find out the patient has an outpatient MRI scheduled for tomorrow morning through the PCP.
The patient was discharged home for his scheduled outpatient lumbar MRI the following day. His neurologic exam remained unchanged. A neuroradiologist had not viewed the images yet but you spoke with your radiologist who noted:
- Edema in the marrow of T12, L2, L3 vertebra of unknown etiology.
- No compression to the spinal cord or within the spinal canal.
- No signs of endplate disc involvement and no paraspinal inflammatory changes present.
The patients PCP calls you in the ED to ask your advice as to the next step for this child.
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First thought, was an EHR thought. Can we poll everyone on presence of burnout due to EHRs and medical documentation?
Second thought:
What was the HEADS exam on this boy?
Third thought:
Fever, weight loss and bone marrow edema would be concerning for malignancy and infection.
Wonder what other thoughts might arise from some of you fellows out there.
Daily fevers for 10 days in an adolescent, significant focal pain following an injury, and weight loss, make bone or disc infection and hematologic malignancy the most likely diagnostic concerns. Given these, the decision to discharge seems incongruous with the severity of the likely underlying condition. But the MRI is scheduled for morning and the arc of illness doesn’t make me think there will be a significant worsening in the next 12 hours. Therefore, discharge is an option and would require assuring normal labs (K, phos, Mg, uric acid and all 3 cell lines on CBC), a conversation with the pediatrician to assure review of the MRI results in a timely manner, and a family that can be reliably called back for admission (have a phone, have transportation). Reasons for admitting are many and can include pain control (this would be the main driver for me), access of MRI images to subspecialists, convenience to family, and possibly initiating antibiotics according to the newer osteo pathway at this institution.
Interesting case – 17 yo with lower back pain x 6 weeks with fever, weight loss. Possible trigger from river tubing. So if I saw this patient in the ED I’d be concerned. It’s not often a healthy adolescent presents with fever and back pain. My initial concern is whether those 2 symptoms are connected because the differential of fever and back pain is not a pleasant list of illnesses (unintentional weight loss is also a red flag). So I would try to address the potential badness first. That list includes infections (like osteomyelitis, spinal abscess), oncologic conditions, inflammatory/rheum conditions (like ankylosing spondylitis). So I’m on board for CBC, culture, LDH, UA, CRP, ESR. I’d likely get an MRI too and ok with him going home (if nothing crazy in labs) and doing it as the scheduled outpatient in the morning.
Now this marrow edema — what does that mean?? Why is fluid there — I would think marrow edema would carry the same differential as above — maybe also to include things like stress fractures that you might not see on plain film (which I assume he got and was unremarkable if he’s been through Ortho and physical therapy before). So is it possible he has trauma to the spine and coincidentally a febrile condition? Or does this marrow edema link the symptoms. What have we crossed off though?? Maybe just spinal abscess from the list above.
As Maybelle discussed above, I’d investigate more history — recent travel for instance or risk of TB exposure?? Pott’s ?? or other infections not common in this area like dengue??
Strength, reflexes, etc above are reassuring. Depending on the resources available to the family, I do think this patient can be managed as an outpatient. I might have a pow-wow on the phone with Rheum and ID to probe other ideas for testing if the MRI read from Neuro rads doesn’t add anything else. Would also like to know the UA/LDH labs.
This may be my young-clinician tendency to be more conservative in general – but a febrile, tachycardic adolescent with focal bony back pain and elevated inflammatory markers is osteo until proven otherwise, no? I’ve seen patients with osteo become so sick so fast that I think I would’ve admitted the patient after the original presentation and labs.
What suggests to more experience attendings that he can be managed as an outpatient? Is it the chronicity of his symptoms?
During residency I saw a patient with CRMO, and would add it to the differential for this case.
-Monica