Case by Chidimma Acholonu MD, Children’s National PEM Fellow

A 17-year-old female with no significant PMH presented with 3 days of fever, cough, back pain intermittent headaches, and muscle aches. She reports nausea without vomiting, though she continues to have an appetite. Additionally, she is having suprapubic discomfort but has no dysuria. Her last menstrual period was about 4 weeks ago. She was seen at an urgent care where labs were drawn. She notes that she was instructed to present to CNH for a “workup for Lupus”. Of note, when she presented, she had a rash on her face that has since resolved.

Labs at Urgent Care:
BMP: 136/3.3/103/20/10/0.6/132
CBC: 4.5 WBC/12.8/39.7/ plt 119
Upreg negative
UA: +ketones, 1-5 WBCs, trace bacteria, protein 1+
COVID/Flu negative

T 39.2, HR 131, RR 24, BP 132/78, SpO2 99% RA

General:  Alert.  appropriate for age.  uncomfortably but in no acute distress.  
Skin:  Warm.  moist.  no pallor.  no rash.  normal for ethnicity.  
Head:  Normocephalic.  atraumatic.  
Neck:  No lymphadenopathy
Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  normal conjunctiva.  no discharge.  vision grossly normal.  
Ears, nose, mouth and throat:  Oral mucosa moist.  No pharyngeal erythema or exudate.  
Cardiovascular:  Tachycardic with a regular rhythm
Respiratory:  Tachypneic, respirations are non-labored.  diminished breath sounds in the bases bilaterally.  
Chest wall:  No tenderness
Musculoskeletal:  Normal ROM.  normal strength.  diffuse tenderness of the lumbar and thoracic back. No paraspinal tenderness. Bilateral diffuse tenderness of bilateral anterior lower extremities. No calf size discrepancy, redness or swelling.  
Gastrointestinal:  Soft.  Nontender.  Nondistended.  Normal bowel sounds.  
Neurological:  Alert.  No focal neurological deficit was observed.  CN II-XII intact.  

Chest X-ray unremarkable and respiratory viral panel negative. Urinalysis with 1+ ketones and 1+ protein, but not consistent with UTI. The patient had a near syncopal event in XR. She complained of dizziness with a worsening headache, but the neuro exam remained unremarkable. No meningeal signs. After Toradol and reassessment, the headache nearly fully resolved. She continued to have thoracic and lumbar point tenderness without paraspinal tenderness or fecal or urinary incontinence. Back pain is worse with flexion and extension. No additional complaint of leg pain.

MRI Thoracolumbar Spine with Contrast was completed while in the ED. Unable to complete the full study due to anxiety, but partial imaging included full thoracic and lumbar region without contrast. Discussed extensively with neuroradiology who upon evaluating limited study felt there was a lower concern for discitis.

Repeat vitals: T 37.3, HR 98, RR 18, BP 125/65, SpO2 99% RA