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5/14/2013
Morning Report: An Interactive Case Presentation
Mark Wurth MD/PhD
May 18, 2013
Clinical Presentation
14 y/o male presents with 3 day history of progressive low back pain, now limiting his i l b k i
li iti hi
ability to walk.
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HPI details
• Right sided
• Progressively worsening
Progressively worsening
• No preceding injury, remembered, but child plays multiple contact sports
• Some knee pain initially, but now resolved
• No fevers at home, though mom has checked repeatedly because she was concerned about him
• Denies numbness, tingling, weakness, or incontinence
• ROS: negative other than per above.
More History
• PMHx: – Vaccines UTD
Vaccines UTD
– No chronic medical problems/No medications
• PSH:
– Freshman
– Participant in contact sports
– Denies sex/drugs/rock’n roll
• FHx:
– Hashimoto’s thyroiditis in parent
– No hx of other rheumatologic disease
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Differential Diagnosis
Differential Diagnosis
eo
pl
as
tic
us
25%
4.
N
fla
2.
In
25%
fe
ct
io
om
na
t
1.
A
25%
m
m
at
or
y
ic
25%
3.
In
1. MSK
1.
MSK
2. Inflammatory
3. Infectious
4. Neoplastic
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• Adolescent Athletes
– Skeletal Immaturity
– High Rates of Growth
– Organized Sports
• Fewer activities
• Intensive training
– Identifiable Causes
MSK Continued
• Strains, Sprains and Contusions
– Should be a diagnosis of exclusion
– Most common – Management:
•
•
•
•
Icing
NSAIDs
Activity modification
Rehabilitation
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Disks
• Approximately 11% of lumbar pain
• Epiphyseal Ring Fractures
E i h
l Ri F
• Indications for surgery
– Progressive neurological defects
– Cauda equina syndrome
– Persistent pain with severe limitation of activity
• Treatment generally g
y
conservative
– Activity modification
– NSAIDS
– Progressive rehab including core strengthening
Spondylo‐lysis/listhesis
– Peaks in adolescence
– Up to 47% of back pain in Up to 47% of back pain in
athletes
– Only 40% will report specific trauma
– Mechanism: (hyper)extension
•
•
•
•
•
Gymnasts
Dancers
Divers
Weight lifters
Football linemen
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Spondylo‐lysis/listhesis
• Screening
– AP/Lateral/Obilque
• MRI/SPECT
• Treatment
–
–
–
–
Activity modification
Pain control Rehabilitation
Bracing is controversial
• 10
10‐15% will become 15% will become
bilateral
• Few will go on to have neurological impairment
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Anatomic‐ Skeletal
• Scheuermann’s
disease
– 13‐17 year old
– Male predominance
– 80% are painless
– Compensatory lordosis
• Increased pain
I
d i
• Increased listhesis
• Scoliosis
Inflammatory‐ Axial Skeleton •
•
•
•
Reactive Arthritis (Reiter’s syndrome)
IBD Associated Psoriatic Arthritis
Ankylosing Spondylitis
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Commonalities
• Insidious
• Enthesitis
• Gelling phenomenon
• Family Hx
• HLA‐B27 association
Infectious
• Discitis <‐> Vertebral Ot
Osteomyelitis
liti
• Osteomyelitis
• Pyomyositis
• Septic Arthritis
• Sacroiliitis
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Neoplastic
•
•
•
•
Ewing Sarcoma
Osteosarcoma
Leukemia
Metastatic disease
Physical Exam
VS T: 36.8 P:81 R:16 BP:88/44 SpO2:97% RA
Gen: Uncomfortable, still
Gen: Uncomfortable, still
Skin: Warm, dry, no rashes or other eruption
CV: S1 S2, no murmur
Resp: CTAB
GI: SNTND normally active BS
MSK: No joint effusion, ROM full except some tenderness on external rotation of right hip Focally TTP near right SI
on external rotation of right hip. Focally TTP near right SI joint. Some paraspinal muscle spasm present R > L.
Neuro: downgoing toes bilaterally, normal ankle and patellar reflexes, sensation grossly intact
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Differential Diagnosis
eo
pl
as
tic
us
25%
4.
N
fla
2.
In
25%
fe
ct
io
om
na
t
1.
A
25%
m
m
at
or
y
ic
25%
3.
In
1. MSK
1.
MSK
2. Inflammatory
3. Infectious
4. Neoplastic
Workup?
CBC with diff
BMP
ESR
CRP
LDH
Uric Acid
PA/Lateral Spine
PA/Lateral Spine
CT Chest/Abdomen/Pelvis
MRI L‐spine and Sacrum
Bone Scan
Other
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Data
10.3
13.0
91
9.1
277
39.0
136
98
11
4.3
25
0.58
111
77N 14L 9M 0E 0B
CRP: 8.7 ESR: 85 LDH: 111 Uric Acid: 4.5
MRI L‐spine/Sacrum: Right paraspinal muscle strain. No spine infection seen. Differential Diagnosis
eo
pl
as
tic
us
25%
4.
N
fla
2.
In
25%
fe
ct
io
om
na
t
1.
A
25%
m
m
at
or
y
ic
25%
3.
In
1. MSK
1.
MSK
2. Inflammatory
3. Infectious
4. Neoplastic
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Data
10.3
13.0
91
9.1
277
39.0
136
98
11
4.3
25
0.58
111
77N 14L 9M 0E 0B
CRP: 8.7 ESR: 85 LDH: 111 Uric Acid: 4.5
MRI L‐spine/Sacrum: Right paraspinal muscle strain. No spine infection seen. 12
5/14/2013
Data
10.3
13.0
91
9.1
277
39.0
136
98
11
4.3
25
0.58
111
77N 14L 9M 0E 0B
CRP: 8.7 ESR: 85 LDH: 111 Uric Acid: 4.5
MRI L‐spine/Sacrum: Right paraspinal muscle strain. No spine infection seen. Data
10.3
13.0
91
9.1
277
39.0
136
98
11
4.3
25
0.58
111
77N 14L 9M 0E 0B
CRP: 8.7 ESR: 85 LDH: 111 Uric Acid: 4.5
MRI L‐spine/Sacrum: Right paraspinal muscle strain. No spine infection seen. 13
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Missing Something?
• Referred pain?
– Missed Appendicitis
– Pancreatitis
– Biliary Disease
– Renal Disease
Repeat Imaging
CT Neck/Chest/Abdomen/Pelvis with contrast:
Subarticular erosions in the SI joints, suspicious for early changes of sacroiliitis. No evidence of narrowing of the joint space. Questionable osteolytic areas in the S3 segment as discussed. areas in the S3 segment as discussed
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Diagnosis
• CT guided Aspiration – S. aureus
– Started on vanc, transitioned to kefzol
• Rehabilitation and home with PICC for IV Abx
Infective Sacroillitis
• 1‐2% of osteomyelitis/septic arthritis cases
• Treated like osteomyelitis with 4‐8 weeks of antibiotic therapy
• Most common the result of hematogenous
spread
• S. aureus
S aureus most common organism identified
most common organism identified
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Questions?
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