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A 41 year old man with low back pain, fever and cough

Presented by Dr. Naima Akhter Dina

HMO

Department of Physical Medicine & Rehabilitation

Particulars of the patient:

Name Age Sex Religion Marital status Occupation Address Date of Admission Date of Examination : Md. Ishaq Ali : 41 years : Male : Islam : Married : Farmhouse worker : Vill: Mohela, P.S: Kalihati District : Tangail : 16.09.13 : 16.09.13

Chief Complaints:
1. Low back pain for 2 months 2. Fever for 5 months
3. Cough for 5 months

History of Present illness:

According to the statement of the patient he developed low back pain for 2 months which was sudden onset, dull aching in nature, moderate to severe in intensity, localized to low back region, persistent, relieved by walking, associated with morning stiffness (>1 hr) .He gives no H/O joint pain and swelling, headache, redness of eye, bowel/ bladder disturbances.

Present illness (cont)

He also complained of fever and cough for 5 months. Initially for 1 month the fever was low grade, occurred at night, subsided by antipyretic. Then after a afebrile period of 15 days, he again developed fever which was recurrent episodic, high grade, intermittent ( 2 times rise/ day, last for 3 hrs), came with chills and rigor, subsided by profuse sweating.

Present illness (cont)

The highest recorded temp was 104F. The duration of febrile and afebrile period was about 15 days which came alternatively. Fever was associated with anorexia, nausea, vomiting, malaise and fatigue.

Present illness (cont)

He also complained of dry cough for the same duration which was persistent, more at night causing sleep disturbance. He gives no H/O blood with cough, chest pain, breathlessness or significant weight loss.

Present illness (cont)

He is normotensive, non diabetic & non asthmatic. For these above complaints he was seen by Doctor in KSA and treated accordingly on 8.09.13 and now he was admitted in this hospital for better management.

History of Past illness:

He had history of jaundice 8 years back and brucellosis 1 year back which was diagnosed in KSA and he was treated with Cap. Doxycycline (100mg) twice daily and inj. Streptomycin I/M once daily for 21 days. He had no H/O TB, IHD or any surgical interventions.

Drug History:
Patient was taking Cap. Doxycycline 100mg twice daily, Cap. Rifampicine 150mg once daily, antipyretic and analgesic for his illness.

Family History:
He has 2 brothers and he lives with his wife and 2 sons. None of his family members have same type of illness.

Socio-Economic History:
He is the only earning member of his family, lived in KSA for last 9 years where he worked as a farmhouse worker ( goatsheep farm) and earned 25 thousands Tk/ month. In KSA, he lived in a tin-shed house, drank mineral water and did not use sanitary latrine.

Personal History:
He is non-smoker, non-alcoholic & does not take betel nut. He is habituated to normal Bangladeshi and Arabian diet. He had no history of sexual exposure and no history of contact with TB patient.

Immunization History :
He is not immunized as per EPI schedule.

General Examination:
Appearance Body build Co-operation Decubitus Nutritional status Height Weight BMI : anxious : average : co-operative : on choice : average : 5 ft : 55 kg : 24.44 kg/m2

General Examination ( cont)

Anaemia Jaundice Cyanosis Oedema Dehydration Clubbing Koilonychia Leuconychia : : : : : : : : mild absent absent absent absent absent absent absent

General Examination ( cont)

Thyroid gland Neck vein Skin condition Hair distribution Bony tenderness Lymph nodes BCG mark : : : : : : : not enlarged not engorged normal normal absent not palpable present

General Examination ( cont)

Pulse Blood Pressure : 72 / min. : 110 / 70 mm of Hg

Temperature
Resp. rate

:
:

980 F
18 / min.

Musculoskeletal System examination:

Gait : normal

Arms
Legs

: normal
: normal

 Spines: look

feel

- no spinal deformity - no swelling - no muscle wasting - tenderness over L5-S1 region and over left sacroiliac joint present ( grade II ) -step sign : negative

move

-flexion : restricted -extension : restricted -lateral flexion : restricted

Special tests : Modified Schobers test Finger -Floor distance Wall -Occiput distance FABER test Gaenslens test : positive(4 cm) : positive(20 cm) : 0 cm : negative : negative

Special tests : Pelvic compression test Pelvic distraction test Straight leg raising test : negative : negative : 70 degree (both sides) Total chest expansion : restricted (2.5 cm)

Respiratory system examination:

Inspection:

Chest shape Chest movement

Visible pulsation Suprasternal, intercostal or subcostal indrawing

: normal : bilaterally symmetrical : absent : absent

Palpation Position of trachea : central Position of apex beat : left 5th ICS, just medial to mid clavicular line Chest expansion : symmetrical Total chest expansion : restricted (2.5cm) Vocal fremitus : normal

Percussion: Percussion note Auscultation: : resonant

Breath sound
Vocal resonance

: vesicular with no added sound : normal

Alimentary system examination:

Oral cavity Lips, tongue, palate, gum & vestibule are normal.

Abdomen proper Inspection: Shape of the abdomen Flanks Umbilicus Skin condition

: normal : not full : centrally placed, inverted : normal

Superficial palpation Temperature : normal Tenderness : absent Muscle guard : absent Muscle rigidity : absent

Deep palpation: Liver Spleen Kidney Urinary bladder Fluid thrill External genitalia

: not palpable : not palpable : not ballotable : not palpable : absent : normal

Percussion: Percussion note : tympanitic

Auscultation: Bowel sound

: present

Nervous system examination:

Higher psychic function : normal Cranial nerves : intact Motor system : normal Sensory system : normal Sign of menengial irritation : absent Cerebeller sign : absent

Cardiovascular system examination:

Inspection: Chest shape Apical impulse Scar mark Palpation: Position of apex beat

: normal : absent : absent

: left 5th ICS, just medial to mid clavicular line Thrill : absent Left parasternal heave: absent Palpable P2 : absent

Percussion: Area of cardiac dullness : normal

Auscultation: 1st and 2nd Heart sound Added sound

: present : absent

Salient features
Md. Ishaq Ali, 41 years, male, muslim, married, non-smoker, normotensive, nondiabetic, non asthmatic, farmhouse worker in KSA for last 9 years, hailing from Tangail, admitted into this hospital through OPD on 16/09/13 with the complaints of low back pain for 2 months, fever and cough for 5 months.

Salient features ( cont )

The patient developed low back pain for 2 months which was sudden onset, dull aching in nature, moderate to severe in intensity, localized to low back region, persistent, relieved by walking, associated with morning stiffness (>1 hr). He gives no H/O joint pain and swelling, headache, redness of eye, bowel/ bladder disturbances.

Salient features ( cont)

He also complained of fever and cough for 5 months. Initially for 1 month the fever was low grade, occurred at night, subsided by antipyretic. Then after a afebrile period of 15 days, he again developed fever which was recurrent episodic, high grade, intermittent ( 2 times rise/ day, last for 3 hrs), came with chills and rigor, subsided by profuse sweating.

Salient features ( cont)

The highest recorded temp was 104F. The duration of febrile and afebrile period was about 15 days which came alternatively. Fever was associated with anorexia, nausea, vomiting, malaise and fatigue.

Salient features ( cont)

He also complained of dry cough for the same duration which was persistent, more at night causing sleep disturbance. He gives no H/O haemoptysis, chest pain, breathlessness or significant weight loss.

Salient features ( cont)

For these above complaints he was treated with Cap. Doxycycline 100mg twice daily and Cap. Rifampicine 150mg once daily in KSA.

Salient features ( cont)

He had history of jaundice 8 years back and brucellosis 1 year back which was diagnosed in KSA and he was treated with Cap. Doxycycline (100mg) twice daily and inj. Streptomycin I/M once daily for 21 days. He had no H/O TB or contact with TB patient.

Salient features ( cont)

On examination, patient is anxious, mildly anaemic, lymph nodes are not palpable, his pulse- 72 / min, blood pressure- 110 / 70 mm of Hg, temperature- 980F, no deformity of spine, grade II tenderness present over L5-S1 region and left sacroiliac joint, all movements of spine restricted, Modified Schobers test: positive (4 cm), total chest expansion: restricted (2.5 cm), no organomegaly.

Provisional diagnosis

Provisional diagnosis

Brucellar Spondylitis

Differential diagnosis
Recurrent flue like illness with spondyloarthopathy Tuberculosis of spine Undifferentiated Spondyloarthopathy Non specific low back pain with recurrent flue like illness

CBC

1st hospital day 16.09.13

10.3

8th hospital day 23.09.13

12.8

13th hospital day 28.09.13

13.9

Hb%(gm/dl)

ESR (mm in 1st hr) 140

WBC(/cmm) Neutrophil % Lymphocyte% Eosinophil % Monocyte % Myelocyte% 5000 65 30 03

65
2800 24 70 04 02

70
3000 18 68 02 10 02

Platelet count(/cmm)

170000

150000

Investigations (cont)
PBF(23.09.13): RBCs - mild rouleaux formation with anisochromia and anisocytosis WBCs - are mature with above count and distribution Platelets - are normal Comment- Leucopenia with high ESR

Investigations (cont)
PBF(28.09.13): RBCs - mild rouleaux formation with anisochromia and anisocytosis WBCs - are mature with above count and distribution Platelets - are normal Comment- Leucopenia with high ESR

Investigations (cont)
Urine R/M/E S. creatinine FBS 2 hrs ABF S. billirubin SGPT HBsAg Anti-HCV : normal study : 0.7 mg/dl : 76 mg/dl : 105 mg/dl : 0.4 mg/dl : 36 U/L : non-reactive : non-reactive

Investigations (cont)
MT test Sputum for AFB Sputum for Gram stain : negative : negative : both extracellular and intracellular Gram negative diplo cocci is present : no growth

Sputum for C/S

Investigations (cont)

Investigations (cont)
USG of whole abdomen : Normal study ECG Echocardiography : Normal study : Normal study

Chest X-ray ( P/A view)

: normal study

Chest X-ray ( P/A view)

Investigations (cont)
X-ray Lumbo-sacral spine (A/P & lateral view) : grade I spondylolisthesis of L5 over S1 with lumbar spondylosis X-ray both SI joints (Oblique view) : normal study

X-ray Lumbo-sacral spine

X-ray both SI joints (Oblique view)

 MRI of D/L spine & both SI joints:

-degenerative disc & spine disease - L4-L5: disc bulging with corresponding thecal sac indentation - L5-S1: central & both para central disc protrusion with corresponding thecal sac indentation & bilateral foraminal narrowing.

MRI of D/L spine

MRI of D/L spine

 Bone marrow study: - Average cellular marrow with normal M:E ratio
- Erythropoiesis is active and normoblatic - Granulopoiesis is also active and maturing into segmented forms - Megakaryocytes are normal - Lymphocytes and plasma cells are increased - No sign of hemophagocytosis, no granuloma, ectopic cell or parasite is seen Comment: Features suggestive of secondary reactive marrow

Confirm diagnosis

Brucellar spondylitis

Management:
A. General Management:

a. Rest
b. Assurance

c. Patient education
- about - about - about - about disease management outcome prevention

Management(Cont )
B. Specific management: (Acc. to WHO) management of brucellar spondylitis :
Cap. Doxycycline 100 mg twice daily for 6 weeks Cap. Rifampicin 900 mg/day for 6 weeks and Inj. Streptomycin 1 g/day IM for 3 weeks.

Management(Cont )
-Others:
Cap. Indomethacine Cap. Omeprazole Tab. Tolperisone Tab. Levosulbutamol

Management(Cont )
ADL advices: -avoid heavy lifting -use firm mattress and single pillow

Present condition of the patient:

Symptoms: Fever Cough Low back pain

- subsided - improved - improved

On examination: All movements of spine - restored Expansibility of chest - restored

 CBC (05.10.13): Hb% ESR WBC Neutrophil Lymphocyte Monocyte Eosinophil Basophil Platelet count

- 11.0 gm/dl - 43 mm in 1st hr. - 4260/cmm - 30.5% - 56.8% - 6.6% - 5.9% - 0.2% - 216000/ cmm

 PBF (05.10.13): RBCs - normochromic and normocytic WBCs - are mature, total and differential counts are within normal limit Platelets - are normal No MP is seen Comment: Non - specific morphology

Follow-up:
essential for ensuring that the patient complies with the full 6-week antibiotic regimen continued until the infection is cured and laboratory findings return to reference ranges. to monitor the course of low back pain

Prevention:
Avoid potential sources of infection
-avoiding infected animals -using precautions(eg, gloves and mask)when dealing with a potentially infected animal -avoiding potentially contaminated foods

For farmers, immunization of cattle against the disease For laboratory workers, maintenance of the appropriate level of containment

Thank You