Transcript Johnson- Conundrum-Thoracic (T2) osteomyelitis

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
Medications
 Acetaminophen 80mg prn fever
 Ibuprofen 80mg prn fever
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.
Differential Diagnosis
Labs/Studies
CBC
BMP
Urinalysis
Liver Function Tests
Inflammatory
Markers
Body Fluid Analysis
Pathology
Microbiology
CXR
CT Scan
MRI
2-D Echo
Other Studies
Other Imaging
Clinical Course
CBC
9.2
1,189
20.3
27.2
Neut 52, Lymph 38, Mono 8
MCV 77
BMP
133
102
4.8
22
5
0.5
Ca 9.2 (8.8-10.5)
88
Urine Analysis
Sp. G.
pH
Blood
Ketones
Glu
Prot
LE
Urobil
Bili
> 1.030
7.5
negative
negative
negative
1+
negative
negative
negative
Micro – no RBC, no
WBC
Liver Function Tests
AST
ALT
Alk. Phos
Bilirubin
Total protein
Albumin
48 (20-50)
63 (20-50)
102 (40-125)
0.2 (0-1.1)
6.6 (6.2-8.3)
3.6 (3.6-4.6)
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
Microbiology








Blood culture negative
Urine culture negative
CSF culture negative
CSF enterovirus PCR negative
EBV titers negative
CMV titers negative
Viral Respiratory PCR negative
PPD negative
CXR
IMPRESSION: Peribronchial thickening
consistent with bronchiolitis or reactive
airways disease. No evidence of focal
pneumonia.
CT Scan
CT Scan
CT 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 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.
MRI
MRI
MRI
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
Other Studies
 LDH – 713
 Uric Acid – 2.0
 Culture from spinal abscess –
methicillin sensitive Staph
aureus
Diagnosis
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