Your Diagnosis, Please
A previously healthy 15-year-old boy presented in September to the hospital with a 1-week history of fevers and a variety of musculoskeletal complaints. He initially developed left hip pain 9 days before presentation. He had attributed the pain to long-distance running but could not recall any specific injury. His hip pain gradually resolved over the next 48 hours. The following day, he developed fever, headache and upper back pain. The upper back pain, described as a dull pain located “between the shoulder blades,” worsened over the next few days. Because of this pain, he had difficulty pushing and lifting objects with his arms, and he complained of neck stiffness. He continued to have fevers, and an examination 4 days before presentation was remarkable for mild left lower quadrant abdominal pain to deep palpation without rebound or guarding. The white blood cell count at that time was 6600/µL with a differential of 81% neutrophils, 9% lymphocytes and 10% monocytes. Erythrocyte sedimentation rate was 45 mm/h. Computed tomography of the abdomen and pelvis revealed some pelvic fluid, but there were no signs of appendicitis. He denied any nausea, vomiting or diarrhea. On re-evaluation 3 days later, he was noted to have mild tenderness to palpation between the shoulder blades, as well as pain with neck flexion. Repeat white blood cell count was 15,400/µL with a differential of 75% neutrophils, 13% lymphocytes and 12% monocytes. The erythrocyte sedimentation rate had risen to 77 mm/h. A 2-view chest radiograph was normal. Nevertheless, he continued to have fevers and was referred to the hospital, where an infectious diseases consultation was requested.
The patient lived on a farm in rural northern Kentucky with his parents and was 1 of 13 children. His family had cows, chickens, goats, cats, dogs and a donkey. He helped clean the pens and barn and assisted with routine farming tasks. The cows and goats were not used for milk or for meat. However, the patient and his family members had consumed and made ice cream from unpasteurized milk from their neighbor’s cows. He had been camping in Ohio, Indiana and Kentucky over the summer. He had sustained multiple tick bites but did not recall any rashes.
Physical examination was notable for a generally well-appearing boy who had significant tenderness to palpation over the spinous processes of his upper thoracic spine and over his trapezius muscles bilaterally. No swelling, warmth or erythema was noted over these areas. He had full range of motion of his neck with no meningismus, although he had mild pain with neck flexion. The remainder of his examination was normal.
Laboratory studies included a normal complete blood cell count with differential, but markedly increased inflammatory markers: erythrocyte sedimentation rate of 47 mm/h and C-reactive protein of 23.1 mg/dL. A radiograph of the cervical spine revealed an unsuspected injury and magnetic resonance imaging of the spine established an etiology for the fevers.
For denouement see p. 886.