Nadira Ramkhelawan MD, INOVA Fairfax Children’s Hospital

The Case:
17 year old male with no significant past medical history who presents with worsening back pain for 6 weeks without any preceding trauma, but in the setting of river tubing. Review of systems were significant for weight loss, intermittent fevers, as well as intermittent lower extremity paresthesias. His neurologic examination was unremarkable, however, his MSK exam revealed lumbar spine tenderness as well as painful hip range of motion. Conveniently, this patient already had a scheduled outpatient lumbar spine MRI as part of his PCP’s workup for the following morning.

Here’s How You Answered Our Questions:

Discussion:

This case made for a lively discussion as the majority of providers felt any other child in this situation with the same history and examination findings would require admission for possible osteomyelitis/discitis as the workup continues. However, what threw a wrench into that plan was the fact that he was already plugged into an outpatient MRI in the morning. Dr. Prieto made a good point that infection is high on the differential but as Dr. Simpson pointed out, the chronicity of symptoms made that much less likely. A true spinal abscess, discitis, or osteomyelitis would have flourished and significantly worsened over the 6 week time period.

This case also illustrates how we as physicians must double think all our decisions regarding admission using a risk vs. benefit state of mind. Drs. Cahill and Ward walked us through their thought processes. Risk: increased cost to the medical system, increased cost potentially to the family, requested PTO for a parent that is caring for this child, potential loss to follow up. Benefits: decreased cost and decreased inappropriate resource utilization. The tipping point was whether we are comfortable with an MRI that happens at 4 am vs. 8 am in an adolescent who would not require sedation to obtain an MRI to begin with and was not acutely toxic or decompensating. If admission were the route, what could possibly be gained? Faster read on the MRI, no potential loss to follow up, and two extra sets of vital signs (4 am and 8 am). All in all, this is a unique situation in that although the differential is filled with worrisome diagnoses, as long as this family and PMD are reliable, outpatient workup can continue as scheduled for a fracture of the cost otherwise.

Denouement:

This patient was admitted to the hospital without antibiotics. There was a lower concern for infectious etiology given the MRI findings of no end plate changes, and no inflammatory changes. Neuro radiologist overread the next morning also noted extraosseous tumor extension from the L5 pedicle extending into right L4-L5 and right L5-S1 foramen and slightly also into central canal. All of the findings were highly concerning for neoplastic process. Hematology/Oncology were consulteld as the differential included leukemia, lymphoma, and neuroblastoma. A bone marrow biopsy ultimately confirmed pre B cell ALL.

This presentation with multiple-bone involvement is indeed atypical but not unheard of for pre-B lymphoblastic lymphoma. Upon further consultation with the John’s Hopkins Hematology/Oncology team by INOVA, they had 5-6 similar cases in the last 15 years. They are classified as very high risk Pre B cell ALL patients and treatment protocols are risk stratified as such.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728874/?report=reader

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