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A 14-year-old with lower back pain
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The contributing columnist this month is Michael P. Koster, MD. Dr. Koster received his undergraduate education at the University of Colorado at Boulder followed by medical school at New York Medical College at Valhalla, N.Y. His pediatric residency was done at Schneider Children’s Hospital at New Hyde Park, N.Y. He is currently a pediatric infectious diseases fellow at Hasbro Children’s Hospital, Department of Pediatrics, Division of Pediatric Infectious Diseases, Providence, R.I. – James H. Brien, DO
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Michael P. Koster | James H. Brien |
A 14-year-old white male is seen with a one-month history of lower back pain. The history of this problem began with two weeks of fever with night sweats. However, he has been afebrile for the last two weeks, but the pain in his back persists and still wakes him from sleep each night. He has not complained of any numbness, tingling or weakness of his lower extremities.
His past medical history is that of a normal adolescent boy with no significant medical or surgical problems and whose immunizations are up to date. He recalls sustaining a minor injury to his back while playing basketball sometime before the onset of the above, but not severe enough to seek care. There has been no other injury.
His family history is unremarkable. There are no recent sick exposures or travel, and the only animal exposure is to a new, stray kitten with fleas.
Examination revealed normal vital signs and physical findings of a normal 14-year-old male with only some point tenderness over the L1 area of his back. Specifically, he had clear breath sounds, no adenopathy or rash, and no neurological deficit.
Lab tests included a normal CBC, an ESR of 25 and a C-reactive protein of 3.4.
A tuberculin skin test (PPD) was negative and chest radiograph was clear.
An MRI of his spine revealed enhancement and focal osteolysis with marrow edema of the first lumbar vertebral body, consistent with osteomyelitis of the L1, as shown in Figure 1. Figure 2 also shows a paraspinal phlegmon extending from the 12th thoracic vertebrae to the second lumbar vertebrae, with no abscess.
He was admitted and treatment was begun with intravenous vancomycin plus ceftriaxone, pending stains and cultures done by needle aspiration under CT-guidance.
What’s Your Diagnosis?
- Salmonella osteomyelitis
- Staphylococcus aureus osteomyelitis
- Bartonella henselae osteomyelitis
- Mycobacterium tuberculosis osteomyelitis
Case Discussion
Paired serology supported the diagnosis of (C) Bartonella henselae osteomyelitis. Bartonella henselae is a small, fastidious, intracellular, Gram-negative bacillus with a high affinity for the endovascular endothelium. Most commonly it causes fever with lymphadenopathy, the typical "cat scratch disease," as shown in figure 3, and is a common cause of fever of unknown origin and occasionally causes hepatosplenic disease (Figure 4). Osteomyelitis however is a rare presentation of this very interesting disease, but as this case and others (Figure 5) have shown, it does occur. The adenopathy is not necessarily restricted to the cervical, epitrochlear or axillary nodes, but as figure 6 shows, it can also be a cause for retropharyngeal adenopathy and cellulitis. Both patients in figures 5 and 6 had positive B. henselae IgM titers.
Tuberculous vertebral osteomyelitis, or Pott’s disease (Sir Percival Pott; 1714-1788) is a very uncommon infection in this country. But when it is seen, it may follow a very similar history as the case presented. However, the fact that there was no known exposure, visit to an endemic area, any pulmonary disease (the usual port of entry to the bloodstream) or a positive PPD, the possibility of Mycobacteria tuberculosis becomes very unlikely. Even though Pott’s disease may be rare in this country, you do not have to look too far to find it in developing countries, as shown in figure 7, the typical kyphosis seen in a case of Pott’s disease as seen by Louis Giangiulio, MD, when he was an Army pediatrician assigned to Afghanistan.
Salmonella vertebral osteomyelitis (Figure 8) would be a good thought in a patient with sickle cell disease, but would likely have a more acute onset. Obviously, in this country, these children are almost always going to be African Americans.
Most cases are going to be caused by Staphylococcus aureus, and again likely to be more acute in onset. Initial therapy should include coverage for MRSA until the etiology is known. In this case, the aspirate was negative for bacteria, acid-fast organisms and fungi.
Therapy for cat scratch osteomyelitis is not well studied, but there are some limited data supporting the use of rifampin, which, along with ciprofloxacin, was used in this case with good results. Some may advocate no therapy and others may use two drugs for six weeks. The best bet is to consult your local infectious diseases specialist for treatment recommendations if and when you should happen to have one of these cases.
To read more about vertebral osteomyelitis in general, look at last month’s issue of Infectious Diseases in Children for an excellent review by Hollon and Eberly in the Resident Rounds section.
Columnist comments
Fort Hood; what can I say? I have a long history with Fort Hood, both on active duty and since retirement. It lies about 15 miles from our home, and my wife and I were on post there when the shootings took place. We were at the PX refilling prescriptions and doing some shopping when it happened several blocks away. We learned that something was wrong when an announcement was made over the public address system that the post had been "locked down," which meant we could not leave the building. Over the next three hours, we received bits and pieces of information via cell phone and from other customers and employees.
After being released from the building, it took another hour to get off post because of an enormous traffic jam, as all cars were being searched before exiting the various gates. Despite this, I saw no one complain or lose their temper, but rather everyone was very considerate of everyone else. And then it occurred to me that active duty and retired soldiers and their dependents seem to posses a special bond that I had temporarily forgotten about until that day; something like a very large family, and I felt a mixture of pride and sadness. The shooter, an active duty psychiatrist, was first brought to our hospital, Scott & White, for initial surgery and stabilization, and then transferred to Brooke Army Medical Center in San Antonio the next day for security reasons.
Naturally everyone wants to know "how could such a thing happen," and the answer will be the subject of debate and investigation for some time to come. One thing does not need analysis, and that is that this individual does not represent the Army Medical Department, particularly the Medical Corps (physicians). No one person does. His medical school, the Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, is one of the finest medical schools in the country, with one of the most demanding entrance requirements. I know. I used to be on their admissions committee. I also happen to know that the Psychiatry Department at Walter Reed has very high standards with an outstanding reputation. These facts do not change just because this disturbed officer was educated and trained at those facilities.
My support for our military, particularly our physician brothers and sisters-in-arms, has not and never will change, and I hope yours does not either.
James H. Brien, DO, is Head of the Pediatric Infectious Diseases Section at The Children’s Hospital at Scott and White and is the Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbrien@aol.com.