What makes you think endocarditis in this case?

Type, dose, route, and reasoning please.

I like this. Lets imagine you were a smart medic and brought a few Binax kits on the trip with you since you knew you were going to a malaria zone. Just a tiny little card that can give you instant screening for Malaria (developed here at Walter Reed, FWIW). The gold standard is still thick and thin smears, but this is small, fast, light, and effective. Your PT's BinaxNOW results are negative.

ANYONE with a fever and a relevant travel history has malaria until proven otherwise. It may be malaria/AND, but you always rule out malaria.

Upon oral inspection you see the results of years of chewing tobacco and poor oral hygiene, and a number of fillings that the patient confirms are recent. Moderate gingivitis and halitosis is noted.

Alright, so what you're saying is that the patient had/has bacteremia secondary to the dental procedure, and now has osteomyelitis secondary to the bacteremia. The presumptive diagnosis in that case is osteomyelitis. Endocarditis is another possible and highly concerning complication of bacteremia, and yes clinically silent endocarditis is possible. Aggressive screening for endocarditis moving forward is absolutely warranted. However, I think calling it the presumptive diagnosis is a bit of a stretch, and endocarditis is definitely not causing the osteomyelitis in this case.

Since we're talking about sepsis as a possible complication, what is it and how would we recognize it?

This depends on what is on hand.

I doubt we have vancomycin available, and his hydration status keeps me from wanting to further stress his kidneys.

I would choose clindamycin (good coverage for oral bacteria, covers some strains of MRSA and also effective against malaria) - given the clinical scenaria I would give IV if possible/available. I would dose at 600mg IV q8hrs.

Prior to starting Abx can we draw a blood sample for culture (to be analyzed at the facility to which we are heading)? It's best to ID the bug so treatment can be tailored based upon sensitivities (if available).


The reason some of us want to rule out bacterial endocarditis is because transient bacteremia during/following dental work can lead to cardiac bacterial vegetations that shower off bacteria, may cause septic emboli and persistent bacteremia which would put him at risk of further end-organ infections.

Absolutely agree on the endocarditis! Ruling it out is crucial, and continued surveillance is also crucial. I just objected to it being the presumptive diagnosis and cause of the osteomyelitis.

I'm happy with that treatment plan. Clindamycin seems reasonable if you have it. Rocephin would also be a reasonable broad spectrum agent a medic is likely to have available. Start treating this right away!

So, treatment plan:
Start IV antibiotics immediately (agent selected based upon availability)
Pain Control?
Medevac imediately
Reassess, reassess, reassess

Unanswered 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?

4. Since we're talking about sepsis as a possible complication, what is it and how would we recognize it?

I'd be worred that ceftriaxone doesn't cover strep viridans groups and MRSA which both can cause a nasty osteomyelitis, but you have to choose from what's available.

I would be monitoring him closely during and after the first dose of antibiotics in case he goes septic from endotoxin/toxic shock - would have IV fluids ready to run open wide for pressure support and be checking blood pressure and extremity perfusion frequently. I've seen several patients crash within 1-2 hours of the first antibiotic dose (typically gram negative bugs in those cases).

For pain control I would hold off on systemic treatment for now - motrin can affect platelet adhesion and if he starts to head down the line towards DIC I don't want to contribute to bleeding issues. For the concern of shock above I would prefer not to administer narcotics as well so I can keep an eye on mental status.

My thought is that MRSA is a lower risk given our proposed mechanism, so I wouldn't make MRSA coverage my treatment priority. Agree that a good portion of Strep Viridans is resistant to Rocephin, so it might not be an ideal agent... I'm just running over in my mind what a medic is likely to have. Someone with more current knowledge of what is in an 18D's aid bag than myself would be better to answer this definitively.

Fair call on the pain control.

Red Flags
 

The point of this case is to illustrate an example of a "red flag." Back pain is an unbelievably common complaint, especially in the military. Most of the time, back pain is a relatively self-limiting condition requiring only some supportive treatment and the tincture of time. However, there are a number of extremely dangerous causes of back pain that can masquerade as lumbago. Obviously, we're not going to go full House MD every time a team-mate has a little back ache, so we need some screening questions to identify those back pain cases that need more thorough investigation. This list is not exhaustive, but it covers some of the most important issues to look out for.

Red Flags: Fever, Night Sweats, Unexplained Weight Loss
Why we're concerned? Infection, Rheumatologic Disease, Cancer

Red Flags: Personal History of Cancer, Constitutional Symptoms, New onset at age > 50 w/o clear mechanism
Why we're concerned? Cancer

Red Flag: Age <18
Why we're concerned? Stress fractures, infection, discitis

Red Flag: Unrelenting nocturnal pain
Why we're concerned? Cancer, osteoid osteoma

Red Flag: History of Trauma
Why we're concerned? Fracture

Red Flag: Numbness or sensation change, neuro findings on PE
Why we're concerned? Nerve root compression

Red Flag: Bowel or bladder incontinence, "saddle" sensation changes
Why we're concerned? Cauda Equina Syndrome

Red Flag: IV drug use, immunosuppressed status (IE corticosteroid use!)
Why we're concerned? Infection

(to be clear, the red flag finding does not diagnose the concern! It is just an important finding that should prompt further investigation)

[QUOTE=DocIllinois;532354]This looks good to me. I would simplify the flexion/extension response for the sake of non-bone-benders and say that because of the physics involved, increased pain on flexion points to a problem on the anterior portion of the spine (body, discs, etc) while increased pain/symptomology on extension suggests a posterior etiology. Its an over-simplification perhaps, but a good rule-of-thumb. Osteomyelitis generally infects the vertebral body due to its vascularity.

As for the kidneys, the first thing is that the location I'm describing is pretty specific. It really only hurts when you mess with his vertebrae. The muscles are fine. No costo-vertebral tenderness. No referred pain. This is a very focal issue. We also don't have any exciting findings related to his urine. He's a little dehydrated (hence the yellow urine) like every team guy in the field ever, but no changes in urinary habits, the pain isn't associated with urination, and our dipstick revealed no heme or protein. Stones and the like also tend to be colicky pain, not continuous pain. None of this is to say that we can forget this guy's kidneys, but these findings move primary renal issues lower on our differential.




So, any last wrap up? Hopefully this has been helpful, and I welcome any of the real doctors here to chime in and correct any errors I've made.

[QUOTE=DocIllinois;532354]Night sweat - for it to be concerning (from an oncologic standpoint) should be recurring and be sufficient to require change of bedclothes/sheets.

I'll defer to others on the flexion/extension question.

For renal eval - pain tends to be colicky if worried about stones (not constant such as in this case). Most commonly docs will pound on the costovertebral angle to check for kidney-associated pain (such as in pyelonephritis). Since kindeys are retroperitoneal the abdominal examination is less helpful (unless there is a large kidney mass - this will be picked up on abdominal exam). Other things associated with a renal cause - hematuria, cloudy/foul smelling urine (UTI progressing to pyelonephritis), other urinary symptoms (hesitancy, frequency, dysuria).

Sepsis is a lecture unto itself - different causes (hypovolemic, spine trauma, sepsis, cardiogenic, etc.) - compensated versus not, one could go on for a long time and I'm admittedly a bit rusty on the specific pathophysiology in these different scenarios.

[QUOTE=DocIllinois;532372]Cheers!

Perhaps I'll consider that next go.