Thread by @SatyaPatelMD

1/16 Yet another fantastic AM report @LosAngelesVA!

Facilitator: @BrandonCSmithMD
Presenter: Danny Xu, MD (@uclaimchiefs PGY-2)

CC: lower back pain (LBP)

#MedTwitter #MedEd #FOAMed

2/ Brandon asked the group three questions:
1⃣ What is your approach to the pain?
2⃣ How does that inform your next steps for history and physical?
3⃣ How does that inform your next diagnostic steps?

3/ Group answers:
1⃣ We discussed an approach that is nicely captured by this slide

https://twitter.com/BrighamChiefs/status/1278732504266989569

2⃣ The group wanted to know the tempo, progression and radiation
3⃣ Imaging at this juncture seemed premature but the thought was entertained

4/ Elderly male with h/o chronic LBP 2/2 spinal stenosis presented with acute on chronic progressive LBP and BLE weakness over the past 2 weeks prior. Symptoms progressed despite prednisone 20mg x2 weeks.

5/ Patient noted some subjective night sweats + fevers + noted seeing “flowers in eyes”, prompting code stroke which showed no significant pathology.

AMS resolved spontaneously in the emergency room.

6/ Fam hx - mother had Sjogren’s
Traveled to China and Thailand multiple times per year on mission trips
Denied any IV drug use

7/ Notable VS: BP 155/80
Exam: A+O x2 (baseline higher per family), 3/5 BLE strength (limited by pain), normal reflexes throughout, sensation intact to light touch throughout
R 3rd toe: “spot” that was new x1 week

8/ At this time, we took a ⏸️. Where do we invest our cognitive effort? We chose to use the frame suggested by @kelleychuang and proceeded with caution: image-negative back pain with encephalopathy

9/
WBC 15, Hb 14.1 Plt 122
Na 132, HCO3 21, BUN 3.2, Cr 1.8 (baseline 1.2)
UA sp gr 1.05, 2+ prot, 1+ blood, many WBCs, some bacteria
AST 119, ALT 89
Lactate normal

10/ Patient developed some tachycardia and was started on broad-spectrum antibiotics since he met 2/4 SIRS criteria.

Developed pleuritic chest pain → trop 0.61, D-dimer 6.38, EKG showed sinus tachycardia

ESR 108, CRP 33

11/ All signs pointed toward systemic inflammation, but where is it coming from?

Given the pleuritic chest pain and sinus tachycardia, CTPA was performed showing multiple pulmonary nodules with intermediate cavitation

12/ @primoolMD astutely suggested TB precautions despite other potential causes of systemic inflammation given pattern on imaging and history

MRI brain with gadolinium showed no leptomeningeal enhancement, MRI T-spine and L-spine unremarkable

13/ Where would you go from here?

Given systemic symptoms, TTE was performed which showed large mass on tricuspid valve

Blood cultures came back positive for... MSSA!

14/ Acute active pulmonary TB r/o neg, rheumatologic work-up neg

Patient later divulged using testosterone injections at home

15/ What about the "flowers in eyes"? Ophthalmology is consulted and Roth spots were seen!

Re-examination of fingers showed splinter hemorrhages

Re-evaluation of MRI L-spine with neuro team showed L4-L5 discitis

Spot on toe thought to 2/2 embolic phenomenon

16/16 Take-home points
⭐️ Systemic manifestations of endocarditis are not exclusively from L-sided vegetations
⭐️ Re-discuss imaging with subspecialists when additional information comes in as this frames the read