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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