63-Year-Old Woman with Acute Lower Back Pain

1. 63-Year-Old Woman with Acute Lower Back Pain Evan Atkinson Medicine-Pediatrics HO3 Medicine Case Conference LSUHSC New Orleans March 19, 2013

2. Chief Complaint ~“My back hurts and I can’t walk for 5 days.”~

3. History of Present Illness • 63-yo woman (with a past medical history of HTN) who was recovering from a mild lumbar strain after slipping and falling in a grocery store two months prior, presented to the ED with complaints of five days of crescendo lower back pain. • Pain is now so severe she cannot walk. • Pain is sharp, centered above her buttocks and non-radiating.

4. History of Present Illness • Exacerbated by walking. • Relieved by lying on side with hips flexed. • Denies any leg weakness or paresthesia. • Denies dysfunction of bowel or bladder. • No additional trauma. • Denies subjective fever or chills.

5. Past Medical History • PMHx: • HTN • Cerebral aneurysm (1998) • OA hands/knees (x10y) • PSHx: • Brain aneurysm clipped (1998) • C-section • Appendectomy • Allergies: • NKDA • Denies food allergies

6. Past Medical History • Meds: • Diltiazem 240mg daily • Metoprolol succinate 50mg daily • Hydrochlorothiazide 25 mg daily • Meloxicam 7.5mg prn: pain • Tramadol 50mg prn: pain • Cyclobenzaprine 10mg prn: spasm • Acetaminophen 325mg prn: mild pain

7. Past Medical History • Social: • Former unit clerk at Charity MICU • Lives locally with family • Social EtOH • History of ½ packs tobacco per day over 45 years • Quit 5 years ago • Denies history or current drug abuse • FamHx: • Mother deceased at 66 yo of gastric cancer • Father deceased at 67 yo of prostate cancer

8. Past Medical History • Health Maintenance • PCP – unknown • Mammogram – 4/12 - negative • Pap – not done in several years • Colonoscopy – never done • Vaccines • Flu - denies • Pneumovax - denies • Tetanus – 4/12

9. Review of Systems • Gen:ø F/C/NS, ø weight changes, ø fatigue • HEENT:ø sore neck, ø oral pain, ø URTI sx • CV/Resp:ø CP/dizziness/syncope, ø SOB • GI:ø pain/N/V/D, ø dysphagia, ø  stools • GU:ø vaginal discharge, ø dysuria • Lymph:ø lumps in neck or under arms • Skin:ø rash, ø known recent trauma • Neuro: occasional H/A … as per HPI • MSK: occasional hand pain … as per HPI

10. Physical Examination VS: Triage: BP 112/69, P 128, R 19 (93% RA), T 102.7°CBP 137/69, P 108, R 25 (99% RA) Gen: Moderate distress and anxious-appearing Non-toxic, lying in bed on her side, cooperative HEENT: Normocephalic/atraumatic Dentition fair but mild gingivitis OP/NT/TM clear No LAD, trachea midline

11. Physical Examination • CV: • Tachycardia, normal S1/S2 • No murmurs, S3 or S4 • Resp: • Tachypnea, symmetric breath sounds • CTAB, No wheezes/crackles/rhonchi • GI: • Obese, non-distended; +Bowel sounds • Non-tender • No hepatosplenomegaly

12. Physical Examination • GU: • External exam normal, no abscess • Ext: • +2 DP, no edema, nails unremarkable • Spine: • Neck supple • L4 spinous process TTP • Paraspinous muscles tense but nontender • Skin: • Nooverlying integument defect • No erythema, warmth, fluctuance, or induration above L4

13. Physical Examination • Neuro: • +rectal tone, no saddle anesthesia • LE tone/strength/sensation normal • Neg straight leg raise • Ambulation deferred o/w unremarkable • MSK: • No effusions or erythema • No limitations in ROM but exam slightly limited due to back pain • No muscle tenderness

14. Labs Na: 141 K: 3.1 (3.6-5.2) Cl: 104 CO2: 25 BUN: 19 Cr: 1.05 Glu: 114 (65-99) TP: 8.1 (6.0-8.0) Alb: 4.3 AST: 37 AP: 100 ALT: 31 GFR: >60 CRP: 10.36 (<0.90) ESR: 20 UA: neg with no microscopic analysis Blood cxs x 2 sets Gonorrhea and Chlamydia - neg WBC: 12.8 (4.5-11.0) Hgb: 13.4 Hct: 37.8 MCV: 83.8 Plt: 198 RDW: 13.7 N 86% Bands: 2% Lymp: 10% Mono: 2%

16. Imaging Studies L-spine: G1 anterolisthesis of L3-L4 (no pars defect), mild degenerative changes MRI: contraindicated due to cerebral aneurysm clip CT ordered

17. Initial Management • Sepsis with unclear source: • Empiric vancomycin and piperacillin-tazobactam • Surveillance for and removal of source • Back Pain: • Neurosurgery consulted • No indication for surgical intervention • Provide hydromorphone and cyclobenzaprine for pain • HTN: • Holding BP meds and monitor closely

18. Hospital Course: Day 2

19. Hospital Course: Day 2 • CT of lumbar spine • No evidence of osteomyelitis/abscess • Multi-level mild degnerative disc disease within thoracic spine

20. Hospital Course: Day 2 Blood Cultures after 28 hrs: Gram Negative Rods in 4 of 4 bottles Continued empiric GNR coverage with piperacillin-tazobactam Vancomycin discontinued Source of infection not definitively identified Back Pain: Improving with less medications Added heat packs and encourage ambulation HTN: Hemodynamically stable off BP meds

22. Hospital Course: Day 2

23. CDC PHIL #1602, http://phil.cdc.gov Hospital Course: Day 4

24. Hospital Course: Day 4 Blood Cultures Eikenella corrodens identified in 4 of 4 bottles Antibiotic coverage changed to ceftriaxone Source of infection still not identified Reviewed risk factors and pursued ancillary studies Entry Site: no risk factors for E.corrodens ø dental work, ingested bones, licking needles ø instrumentation of GU or GI tracts ø IV or percutaneous drug use ø human or animal bites

25. Searching for the Source • Back Pain • Still improving with less use of opioids • Decreased pain on exam but increased ambulation from bed to restroom with only mild pain • HTN • Resume home BP meds • Infection Locus: ancillary imaging studies • TTE/TEE • structurally normal valves, no vegetation • CT Abd • ø abdominal or pelvic abscess, large uterus

26. Hospital Course: Day 7

27. Gallium Scan • Faint increased uptake within the mid to lower lumbar spine slightly left of midline. • More significant osseous changes from prior CT scan • Within right L3-L4 facet joint

28. Clinical Resolution • Day 2: mild-mod pain with ambulation only • Day 9: pain only with deep palpation of L4 • Day 32: ESR-CRP wnl • Day 60: no back pain discharged on a 3-week course of ceftriaxone IV

30. The End ~ Thanks! ~