naima-lbp
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A 41 year old man with low back pain, fever and cough
Presented byPresented by
Dr. Naima Akhter Dina Dr. Naima Akhter Dina HMOHMO
Department of Physical Medicine &Department of Physical Medicine &
RehabilitationRehabilitation
Particulars of the patient:Particulars of the patient:Name : Name : Md. Ishaq Ali
Age Age : 41 years
SexSex : : Male
Religion : Religion : Islam
Marital statusMarital status : : Married
Occupation Occupation : : Farmhouse worker
Address : Address : Vill: Mohela, P.S: Kalihati
District : Tangail
Date of Admission Date of Admission : : 16.09.13
Date of Examination : 16.09.13 Date of Examination : 16.09.13
Chief Complaints:Chief Complaints:
1. Low back pain for 2 months
2. Fever for 5 months
3. Cough for 5 months
History of Present illness: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…)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…)Present illness (cont…)
The highest recorded temp was 104˚F. 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…)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…)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: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:Drug History:
Patient was taking Cap. Doxycycline 100mg twice daily, Cap. Rifampicine 150mg once daily, antipyretic and analgesic for his illness.
Family History: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 HistorySocio-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 ( goat-sheep 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: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 :Immunization History :
He is not immunized as per EPI schedule.
General Examination:General Examination:Appearance : anxious
Body build : average
Co-operation : co-operative
Decubitus : on choice
Nutritional status : average
Height : 5 ft
Weight : 55 kg
BMI : 24.44 kg/m2
General Examination ( cont…)General Examination ( cont…)
Anaemia : mild
Jaundice : absent
Cyanosis : absent
Oedema : absent
Dehydration : absent
Clubbing : absent
Koilonychia : absent
Leuconychia : absent
General Examination ( cont…) General Examination ( cont…)
Thyroid gland : not enlarged
Neck vein : not engorged
Skin condition : normal
Hair distribution : normal
Bony tenderness : absent
Lymph nodes : not palpable
BCG mark : present
General Examination ( cont…) General Examination ( cont…)
Pulse : 72 / min.
Blood Pressure : 110 / 70 mm of Hg
Temperature : 980 F
Resp. rate : 18 / min.
Musculoskeletal Musculoskeletal System System examination:examination: Gait : Gait : normal
Arms : Arms : normal
Legs :Legs : normal
Spines:
look look - no spinal deformity- no spinal deformity
- no swelling- no swelling
- no muscle wasting- no muscle wasting
feel - 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 Schober’s test : positive(4 cm)
Finger -Floor distance : positive(20 cm)
Wall -Occiput distance : 0 cm
FABER test : negative
Gaenslen’s test : negative
Special tests :
Pelvic compression test : negative
Pelvic distraction test : negative
Straight leg raising test : 70 degree
(both sides)
Total chest expansion : restricted
(2.5 cm)
Respiratory system examination:Respiratory system examination:
Inspection:
Chest shape : normal
Chest movement : bilaterally
symmetrical
Visible pulsation : absent
Suprasternal, intercostal
or subcostal indrawing : 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 : resonant
Auscultation:
Breath sound : vesicular with
no added sound
Vocal resonance : normal
Alimentary system examination:Alimentary system examination:
Oral cavity Lips, tongue, palate, gum & vestibule
are normal.
Abdomen proper
Inspection:
Shape of the abdomen : normal
Flanks : not full
Umbilicus : centrally placed,
inverted
Skin condition : normal
Superficial palpation
Temperature : normal
Tenderness : absent
Muscle guard : absent
Muscle rigidity : absent
Deep palpation:
Liver : not palpable
Spleen : not palpable
Kidney : not ballotable
Urinary bladder : not palpable
Fluid thrill : absent
External genitalia : normal
Percussion:
Percussion note : tympanitic
Auscultation:
Bowel sound : present
Nervous system examination: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 Cardiovascular system examination:examination:
Inspection:
Chest shape : normal
Apical impulse : absent
Scar mark : absent
Palpation:
Position of apex beat : 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 : present
Added sound : absent
Salient featuresSalient features
Md. Ishaq Ali, 41 years, male, muslim, married, non-smoker, normotensive, non- diabetic, 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 …)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…)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…)Salient features ( cont…)
The highest recorded temp was 104˚F. 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…)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…)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…)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…)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 Schober’s test: positive (4 cm), total chest expansion:
restricted (2.5 cm), no organomegaly.
Provisional diagnosisProvisional diagnosis
?
Provisional diagnosisProvisional diagnosis
Brucellar Spondylitis
Differential diagnosisDifferential 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 day16.09.13
8th hospital day23.09.13
13th hospital day28.09.13
Hb%(gm/dl) 10.3 12.8 13.9
ESR (mm in 1st hr) 140 65 70
WBC(/cmm) 5000 2800 3000
Neutrophil % 65 24 18
Lymphocyte% 30 70 68
Eosinophil % 03 04 02
Monocyte % 02 10
Myelocyte% 02
Platelet count(/cmm)
170000 150000
Investigations (cont…)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…)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…)Investigations (cont…)
• Urine R/M/E : normal study
• S. creatinine : 0.7 mg/dl
• FBS : 76 mg/dl
• 2 hrs ABF : 105 mg/dl
• S. billirubin : 0.4 mg/dl
• SGPT : 36 U/L
• HBsAg : non-reactive
• Anti-HCV : non-reactive
Investigations (cont…)Investigations (cont…)
• MT test : negative
• Sputum for AFB : negative
• Sputum for Gram stain : both extracellular
and intracellular
Gram negative
diplo cocci is
present
• Sputum for C/S : no growth
Investigations (cont…)Investigations (cont…)
Investigations (cont…)Investigations (cont…)
• USG of whole abdomen : Normal study
• ECG : Normal study
• Echocardiography : Normal study
• Chest X-ray ( P/A view) : normal study
Chest X-ray ( P/A view)
Investigations (cont…)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 diagnosisConfirm diagnosis
Brucellar spondylitis
Management:Management:
A. General Management:
a. Rest
b. Assurance
c. Patient education
- about disease
- about management
- about outcome
- about prevention
Management(Cont … )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 … )Management(Cont … )
-Others:
Cap. Indomethacine
Cap. Omeprazole
Tab. Tolperisone
Tab. Levosulbutamol
Management(Cont … )Management(Cont … )
ADL advices:
-avoid heavy lifting
-use firm mattress and single pillow
Present condition of the patient:Present condition of the patient:
• Symptoms:
Fever - subsided
Cough - improved
Low back pain - improved
• On examination:
All movements of spine - restored
Expansibility of chest - restored
• CBC (05.10.13):
Hb% - 11.0 gm/dl
ESR - 43 mm in 1st hr.
WBC - 4260/cmm
Neutrophil - 30.5%
Lymphocyte - 56.8%
Monocyte - 6.6%
Eosinophil - 5.9%
Basophil - 0.2%
Platelet count - 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: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: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
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