August 1, 2012

August 1, 2012

1. Gymnastics
2. Weight lifting
3. Diving

1.Gymnastics
2.Weight lifting
3.Diving
*Please make your
selection...
88%
0%
13%
1 2 3

18 yo M with back pain

Serositis
Oral ulcers
Arthritis (symmetric, non-erosive)
Photosensitivity
Blood disorders
Renal disease
ANA
Immunologic – dsDNA, anti-Smith, false +RPR
Neurological – seizures, psychosis
Malar rash
Discoid rash

Drug Side Effects
NSAIDs Gastritis, UGIB, Renal failure
Hydroxychloroquine Macular damage, Stevens-Johnson syndrome, Myopathy
Corticosteroids Adrenal suppression, Immunosuppression, Infections,
Osteopenia, Avascular necrosis of bone, Myopathy
Mycophenolate Myelosuppression, Infection
Cyclophosphamide Myelosuppression, Myeloproliferative disorders,
Immunosuppression, Hemorrhagic cystitis, bladder cancer,
Infertility, teratogen
Azathioprine Myelosuppression, Hepatotoxicity, Lymphoproliferative
disorders
Methotrexate Myelosuppression, Hepatotoxicity, Pneumonia +/- fibrosis,
Alopecia, stomatitis
Cyclosporine Hyperplastic gums, HTN, Hirsuitism, Renal impairment,
anemia
Rituximab B-cell depletion, PML

Temp: 37.1 C HR: 91 RR: 20 O2 sat: 98% on RA BP: 119/68
General: well-developed, well-nourished, no distress but uncomfortable
HEENT: PEERL, no LAD, OP clear without exudates, anicteric sclera,
neck supple
CV: RRR, 2+ pulses throughout, no murmurs
Resp: CTAB/L, no wheezing or rales
Abd: soft, NT, ND, normoactive BS, no masses
MSK: No tenderness on palpation, but patient able to localize pain to
mid-line thoracic area, just below the scapula, ~T4-5. Non-tender
paraspinal area. Normal ROM of waist/hip/knees/ankles and upper
extremities, but difficulty with straight leg raise bilaterally and
flexion/extension at waist 2/2 back pain. No CVA tenderness
Neuro: Normal reflexes throughout, CN II-XII grossly intact. Normal
gait, sensation, coordination, and muscle tone and strength. No clonus
Skin: No rashes

Musculoskeletal
Nonspecific MSK back pain
Spondylolysis/spondylolisthesis
Scoliosis
Scheuermann disease
Disc degeneration, herniation
Infectious
Discitis
Vertebral osteomyelitis
Pott disease (TB)
Epidural abscess
Sacroiliac joint infection
Non-spinal infection:
Paraspinous muscle abscess (pyomyositis)
Pyelonephritis
Pneumonia
PID
Endocarditis
Viral Myalgias
Inflammatory
Ankylosing spondylitis
Psoriatic arthritis
IBD-associated arthritis
Reactive arthritis
Transverse myelitis
Neoplastic
Osteoid osteoma
Leukemia or lymphoma
Solid malignancy, primary or metastatic
Benign tumor
Other
Appendicitis
Sickle cell pain
Cholecystitis
Pancreatitis
Chronic recurrent multifocal osteomyelitis
Psychosomatic illness
Nephrolithiasis

1.Diskitis
2.Gaucher
disease
3.Potts disease
4.Scheuermann
disease
5.Spinal cord
tumor

*Findings are consistent
1.Diskitis
2.Gaucher disease
3.Potts disease
4.Scheuermann
disease
5.Spinal cord tumor
0%
with...
23%
0%
77%
0%
1 2 3 4 5

1.Edrophonium test
2.Lumbar puncture
3.MRI of the spine
4.Nerve conduction
velocities
5.Somatosensory
evoked potentials

*Tests to help lead
1. Edrophonium test
2. Lumbar puncture
3. MRI of the spine
4. Nerve conduction
velocities
5. Somatosensory evoked
potentials
diagnosis...
0%
10%
87%
3%
0%
1 2 3 4 5

*Acute disorder of LE weakness
and sensory loss
*Frequently post-infectious
*MRI: fusiform swelling of the
spinal cord in the affected
region, bright signal on T2weighted
images
*LP: moderate lymphocytic
pleocytosis with a normal or
mildly elevated protein
concentration
*Steroids controversial

1. Lumbar puncture
2. MRI with contrast of
the spine
3. Postvoid bladder
residual measurement
4. Radiograph of the
spine
5. Voiding
cystourethrography

1. Lumbar puncture
2. MRI with contrast of the
spine
3. Postvoid bladder
residual measurement
4. Radiograph of the spine
5. Voiding
cystourethrography
*Next step...
0%
93%
7%
0%
0%
1 2 3 4 5

*Osteoid osteoma
*Leukemia
*Lymphoma
*Ewing sacrcoma
*Neuroblastoma
*Osteoblastoma
*Osterosarcoma
*Neurofibroma
*Langerhans cell
histiocytosis
(eosinophilic
granuloma)

*CBC: 11.1>13.8/40.8

1.Admit to La Rabida
2.Transfer to Comer
3.Send home with
instructions to
follow-up with PMD
in 1-2 days
*What now?
4%
96%
0%
1 2 3

“Doctor, patient is complaining of
bilateral leg tingling”
4:00 am

*Please make your
1.Continue to monitor,
making sure he’s on
continuous
cardiopulmonary
monitors
2.Order stat MRI
3.Give steroids
4.Give antibiotics
5.Call the PICU fellow
6.Cry
selection...
0%
56%
30%
0%
15%
0%
1 2 3 4 5 6

1 hour later…
* Unable to lift legs but can wiggle toes – sensation
still in tact
* Could not void despite full bladder
* Temperature 104.8F blood culture redrawn
* Transferred to PICU – neurosurgery consulted

MRI results

Spinal epidural abscess
* Fever, spinal pain, neurological
deficits
* Staph aureus and gram negative
bacilli
* Spinal cord damage by:
* Direct compression
* Thrombosis, thrombophlebitis of
nearby veins
* Interruption of the arterial blood
supply
* Bacterial toxins and mediators of
inflammation
* Longitudinal extension common
* Routine labs are seldom helpful

*Blood cultures remained negative
Our patient
*T6-T7 and T10-T11 emergent decompressive laminectomy
*Wound culture: MSSA oxacillin
*PICC insertion
*Paresthesias and LE paralysis resolved after laminectomy
*Continued clonus; LE weakness improving with PT
*Oxacillin changed to ceftriaxone for less frequent dosing
*Repeat MRI in 2 weeks

*Review the epidemiology, diagnostic criteria including typical
dermatological manifestations, and management and treatment
side effects of SLE
*Review the differential for back pain in the pediatric patient
and how to recognize various diagnoses
*Review techniques the approach for a focal physical exam with
a chief complaint of back pain
*Recognize and discuss emergent management of patients with
back pain and associated neurological deficits

*Dewolfe, Craig. Back Pain in Brief. Pediatrics in Review 2002;23;6.
*Nigrovic, Peter A. Back Pain in Children and Adolescents:
Overview of Causes. www.uptodate.com, 2012.
*Nigrovic, Peter A. Evaluation of the Child with Back Pain.
www.uptodate.com, 2012.
*Sabatine, Marc S. Pocket MEdicine, 3rd Ed. Wolters
Kluwer/Lippencott Williams & Wilkins, 2008. Pg 8-14.
*Sexton, Daniel J. Epidural Abscess. www.uptodate.com, 2012.
*Weiss, Jennifer E. Pediatric Systemic Lupus Erythematosus : More
Than a Positive Antinuclear Antibody. Pediatrics in Review
2012;33;62