With back pain, fever and night sweats Potts Disease is also in the differential.
Potts Disease is osteomyelitis of the spine caused by mycobacterium tuberculosis (TB) usually acquired from drinking unpasteurized milk in third world countries.
I've seen one case in an active duty soldier.

That is a very good DDx point. The night sweats initially had me thinking about TB, but it just didn't fit the recent history. Talkin about Zebra's :cool: That fits especially with the immature neutrophils and neutrophilia (leukocytosis with left shift). I guess sometimes the hoof beats are from Zebras. ;)

So has Team Sergeant been drinking unpasteurized milk? Otherwise, I'm thinking the proximate cause for the osteomyelitis is the recent dental work.

Still holding with my original plan to ship TS out on the next thing smokin'. All of the likely possibilities are well outside my ability to adequately treat him in the field.

Kidney stone. Tell 'im to drink a 2-qt canteen full o' water, move out and draw fire.

Amateur here...do let me know if I should stand down...

Has the pt had Chickpox as a child?
Has the pt been under greater than usual stress this past 1-2 months, prior to deploy?

S

Yeah I was thinking the same thing, the pain description is a little out of wack for Shingles.

However, pain and fever / "out of sorts" can on occasion appear up to a few days before visual blistering.

It was a long shot, the only reason I even brought it up is lisinopril has been known to increase chance of herpes zoster.

Another question...how long has pt been on meds, the sweats / out of sorts can be the meds, taking these symptoms out of the mix.

Also, any meds during dental work?

S

No.

No

Abdomen appears unremarkable, is soft and supple in 4 fields w/ no guarding or rigidity. Bowel sounds auscultated.

See vitals.

The patient is in a region with chloroquine resistant malaria, and is on prophylaxis as noted. The patient claims good compliance.

No nuchal rigidity noted. Negative NVD, cough, rhinorrhea, sore throat, etc.

1. Lets say sub-saharan Africa somewhere. I'm not picky for this scenario. Someplace hot that has malaria and a bunch of other bad things. Pick a country.
2. His dad was always complaining about his bad back that he got jumping into Market Garden, but no diagnosis that patient can recall.
3. Could you? Would you? (assuming you have the equipment to do the procedure)
4. Negative nuchal rigidity, photophobia.

Work was done at a military dental facility.

He says his mouth was a real cesspool according to the dentist, but he has trouble remembering any particular words. When you say "root abscess," he seems to think that rings a bell. Local anesthetic was used.

Negative

Yes and yes. Mama ain't happy at home.

PT has been taking lisinopril since his mid 30's. He started the malaria prophylaxis a few days prior to deployment.

The patient does not know if the dentist used any meds other than anesthetic... he just remembers a bunch of needles. He was given a prescription for something by the dentist, but he didn't feel sick so he ignored it.

Now we're getting somewhere! :p (Sorry, couldn't resist; even a former Bravo knows how much sympathy to expect when you tell the medic you FTFSI.)

Two quick questions ...

1) how long has he been taking his Lisinopril, and most importantly the Atovaquone/Proguanil ?

2) What is his race/ethnicity ?


ETA some differential Dx's .....

Dad's back pain came from jump into Holland so we can r/o that being a genetic trait.

Mom's RA is a possible genetic trait. Which in combination with the Lisinopril could exacerbate the back pain which is a possible side effect of Lisinopril.

The back pain can also be a hypersensitivity to the Malarone (would really like to know his race/ethnicity .... I reference the M*A*S*H episode with Klinger and Goldman taking the Primaquine.) Also Black's having an acute hypersensitivity to Malaria drugs.

Also, the combination of the Mararone and the supplements he's taking may be causing an adverse reaction. The effects of some drugs can change if you take other drugs or herbal products at the same time. This can increase your risk for serious side effects or may cause your medications not to work correctly.

Also possible, a combination of all three above.

An echo of his heart would be nice. Can we get a EKG to compare against a baseline?

Lab work - Lites/UA w diff (specifically creatinine level)?

How much ibuprofen/naproxen has he been taking?

Somewhere along the line I missed answering:
Cardiac exam demonstrates RRR, S1/S2 w/o murmurs, gallops, or rubs. PMI @ 5th ICS MCL. No splinter hemorrhages either, but great thinking on all of the above.

Indeed!

PT has previously noted history of HTN.

No peripheral edema noted on exam.

The urine was described as mid-yellow with no heme on dipstick and I will add no proteinurea either.

Medication dates already noted a few posts ago.

He's Caucasian.


You already have the diff... I think chemistries stretch what one might reasonably be expected to have given the scenario.

He has not yet taken any NSAIDs.

Any other physical findings you want to look for or history questions to ask?

I think this covers all the new information, but if I missed something please let me know. You should be honing in on your differentials at this point. Look carefully at the problem list and you should be able to stratify this differential pretty effectively. Moving on, are we going to do anything to treat this guy?

Summary Update:

Subjective:
The patient is a 45 y/o steely-eyed barrel-chested team sergeant who presents to the medic with "lower back pain" of a few days duration. He localizes the pain to the L3 L4 region. The patient denies any history of trauma or significant precipitating event. The patient admits to possible fever and night sweats. The patient denies urinary symptoms, incontinence, impotence (strongly denies this one), or neurologic findings. PT reports urine of "medium yellow" color. PT denies NVD, cough, sore throat, rhinorrhea. No pain association with meals. The patient denies history of easy/unusual bleeding or bruising. The patient admits to poor hydration habits. PT denies unusual dietary exposures such as unpasteurized milk.

O: First noticed a few days ago. Gradual in onset.
P: Nothing helps. Movement, especially lumbar flexion, hurts.
Q: “Sharp”
R: “The pain doesn’t seem to go anywhere else but my back.”
S: “Its pretty f’ing bad or I wouldn’t be asking you for meds.”
T: “It hurts pretty constantly.” The pain has been progressive.

PMH: HTN, Recent Dental Work for suspected tooth abscess. Potential poor compliance on post-procedural medication of unknown type.
SHX: N/A
Medications: Lisinopril (since mid 30's), Atovaquone/Proguanil (started about 10 days ago), Various nutritional supplements for weight-lifting
Allergies: NKA
FHX: Dad always had lower back pain, and mom had RA.
Social History: Patient is a weight lifter who enjoys 200lb snatch. PT admits to high stress levels due to marital issues, possibly related to aforementioned 200lb snatch.

Objective:
Vitals: HR: 90, BP 130/85, RR 14, T 101.5deg
The patient is a WDWN 45 y/o Caucasian male who looks his stated age and presents to medic in moderate distress. He is moderately pale and his movements are constrained and provoke grimaces and profanity. Pertinent physical findings include exquisite tenderness on the vertebral prominence of L3 & L4 with a conspicuous absence of tenderness in the paraspinous muscles. No CVAT. Shoulder exam unremarkable. Visual examination of back unremarkable. Straight leg raise does not provoke sciatic pain. Neuromuscular exam of lower extremities unremarkable with preserved reflexes, sensation, and strength. Valsalva unremarkable. Cardiac exam demonstrates RRR, S1/S2 w/o murmurs, gallops, or rubs. PMI @ 5th ICS MCL. Lungs CTA x3 bilat. No splinter hemorrhages. Abdomen shows no visible lesions and is soft and supple in 4 fields w/ no guarding or rigidity. Bowel sounds auscultated. No nuchal rigidity or photophobia noted. No peripheral edema. Urine dipstick test all WNL.

CBC: 15,000 per mm3 leukocytes w/ 12% bands

Problem list:
Focal Vertebral Pain
Fever
Night Sweats
Pallor
Recent Dental Work for possible abscess
Possible poor ABX compliance
Leukocytosis w/ left shift


**************

Some additional questions:

1. What, precisely, is a "night sweat?"

2. What does "pain greater on flexion than extension" suggest in the context of vertebral back pain? How does this fit with our differential at this point?

3. Renal pathology is absolutely a consideration for low back pain, but there are a number of findings in our history and physical at this point that make renal issues less likely in this patient. What are they?