A case for the residents. (THIS IS A REAL CASE)

[RUOkie]

Chief Complaint: R buttocks pain and "sciatica"

44y/o native American male with history of ESRD (on dialysis) secondary to poorly controlled diabetes and R AKA. Referred by ortho for severe R buttocks and posterior leg pain "like I'm being stabbed" of 2-3 weeks duration with progressive worsening.

PMHx: polysubstance abuse, bipolar disorder, hospitalized for pneumonia 8 weeks ago, IDDM

Social Hx: lives in nursing home, hx. amphetamine and ETOH abuse (clean X5 years)

PE: overweight, hystrionic male, yelling and screaming with any movement. He is in a manual wheelchair. He varies between laughing with the nurse who brought him, and yelling in pain. Refuses to attempt standing secondary to pain complaints. Any hip extension reproduces pain. Pulses are 2+ in the LLE. His RLE AKA incision is well healed. His residual limb is non tender. Sensation is diminished in the distal LLE in a stocking distribution, and strength in the LLE is 5/5 except for the foot intrinsics which are 3/5. The RLE cannot be tested secondary to pain.



What do you do next? (I will give the rest of the info on Monday)

---

Members don't see this ad.

 

[olafa]

any labs? CBC, CMP, blood cx? Is there a suggestion of infectious etiology, septic psoas bursitis? diabetic amyotrophy? Rashes to suggest zoster? HIV myelopathy? How well controlled are the blood sugars?
CRPS? plexopthy?
Physical findings of l-spine exam....?
Any imaging to substantiate a dx?

I know you are trying to spur on a bit of conversation, but I think what I am saying is it could be anything without a little more information.

 

[RUOkie]

No that is the point. This person came to my office last wed. with NO diagnostics.

This is what oral boards are like. A case is presented, and you go next.

What imaging or labs do you want?

On reviewing labs from 6 months ago, HIV was negative. (very good thought). He refused most of the exam because of his pain complaints.

 

[topwise]

What about a little more history first, like how did the pain start, how far down does the pain radiate, etc? What meds is he on? Any fever, night pain, b/b incontinence?

Seems like it would be hard to get much imaging on a guy like that, since he screams in pain when you do anything. I can't even imagine the EMG...

 

[RUOkie]

What about a little more history first, like how did the pain start, how far down does the pain radiate, etc? What meds is he on? Any fever, night pain, b/b incontinence?

Seems like it would be hard to get much imaging on a guy like that, since he screams in pain when you do anything. I can't even imagine the EMG...

Pain came on gradually about 3 weeks ago and then suddenly got severe 2 weeks ago. It starts at the lumbosacral junction only on the right and radiates into the L posterior thigh. However, he also c/o R anterior thigh pain with hip ROM. It hurts "all the time" worse with supine. No bowel incontinence. He has been anuric for years (ESRD).

OK, since no other takers, I'll give the rest of the info.

I saw him in the office last Wed. and I was really concerned for discitis or a psoas abscess. I ordered a MRI with gadolinium, but we needed to coordinate with dialysis. His nephrologist insisted on dialysis both 1 day before, and IMMEDIATELY after the gadolinium. So the MRI was done on Friday morning (3/12)

At 11:30am, the radiologist calls me to tell me "good call, he has a L5-S1 discitis with osteomylitis of both the L5 vertebra and the sacrum. When I looked at the films there is an multilocular abscess, but luckily it does not appear to extend into the epidural space.

We admitted him, and the blood cultures are still pending. Our only spine surgeon in our town was away, so he has been transferred to the big city for a laminectomy.


I posted this to the residents to try to get them thinking critically about how to get the most bang for your buck. I knew I had one chance for diagnostics since this guy is really nuts. Getting the MRI scheduled was a pain in the butt (sorry for the pun ) and the patient is mentally ill, an addict, and known to be a malingerer (I did not mention this earlier intentionally). But he had a severe infection.

 

[PMR 4 MSK]

Excellent case!

Some take away messages - really loud, crazy and obnoxious patients may have real pathology.

It's cases like this that teach you to always CYA. Get the MRI before treating.

Discitis and osteomyelitits may not present with fever in a patient this medically compromised.

Probably either the disease or the treatment is going to kill him.

 

[DistantMets]

Nice case...the other take home there is that any progressive neurologic complaint needs to be followed very closely (especially in an amputee you can't examine very well)

I had a patient that was referred by neurosurgery for an EMG at the VA and the MRI and EMG took too long to get scheduled (typical). We saw him first 3 weeks later and the MRI was still 2 weeks away. We diagnosed a cauda equina on him in the EMG lab. He went from walking normally, no back pain or weakness, to back pain and 4+/5 weakness starting 2 weeks before NS saw him to 1-2/5 wheelchair, incontinent, Max A of 2 to get him on the table 3 weeks later when we saw him. NS admitted him right away for a stat MRI and operated that night. We didn't do any NCS, just needled VMO, TA, Med gastroc and paraspinals on both sides and they all lit up. He was one of those old tough guys that apparently didn't think progressive paraplegia was all that concerning.

 

[RUOkie]

I have not heard of the outcome from surgery, but 3/4 Blood cultures were + for MRSA. If that is all it is, he will do just fine. We have little to no VRSA here (so far) so the vancomycin should take care of it.

 

[PMR 4 MSK]

I have not heard of the outcome from surgery, but 3/4 Blood cultures were + for MRSA. If that is all it is, he will do just fine. We have little to no VRSA here (so far) so the vancomycin should take care of it.

And now you have been exposed to him (not really but the hospital will see it that way) and are susceptible to having to be treated for MRSA yourself. I find hospital rules for MRSA to be illogical. Known MRSA = Gown + glove + mask to go in patient room. The fact that probably 90% or hospital employees have MRSA on their skin = nothing. Find it in someone's nose = make 'em but bactroban up their nose until they no longer culture +, even though they will just re-colonize from themselves and/or their environment.

 

[dc2md]

Great case RuOkie!! Keep them coming.