A 14yearold male with selfresolving right elbow swelling

1
A 14-year-old male with self-resolving right
elbow swelling

• Naiwen D. Tu, M.D. and Heather E. Needham, M.D.
• Department of Pediatrics, Baylor College of
  Medicine
• Houston, Texas

2
Abstract

• A 14-year-old healthy male patient presented with
  a constellation of nonspecific symptoms and was
  found to have daily asymptomatic fevers.
• His case evolved from one that focused on ruling
  out localized musculoskeletal infections or
  malignancy, to identifying the cause of his
  fevers of unknown origin.
• The eventual diagnosis of brucellosis was
  achieved through persistent history-seeking,
  close inpatient observation, and identification
  of the organism through microbiological studies.

3
Background / Objectives

• This case illustrates the potential for chimeric
  / varied presentations of a known zoonotic
  disease
• It highlights the value of a thorough history and
  physical exam, but also demonstrates that the HP
  is a dynamic process
• Inpatient hospitalization and observation proved
  to be the key to successful diagnosis and
  initiation of treatment in this case

4
Case History of Present Illness

• Chief Complaint
• A 14-year-old male with a history of pulmonary
  tuberculosis infection presented with a one-week
  history of right elbow swelling and pain.
• HPI
• He was initially seen by his school nurse 10
  days prior to admission for back pain. He was
  also found to have a fever at that time, which
  resulted in a blood test being drawn from the
  right antecubital region. Patient was unable to
  specify what test was performed nor what results
  were obtained.
• The patient subsequently developed pain in the
  right elbow which progressed over the course of
  one week.
• Pain was associated with swelling and tingling
• Worsened with movement, especially flexion and
  extension
• Somewhat relieved with ibuprofen
• Aside from the recent phlebotomy history, the
  patient reported no other trauma to the arm.

5
Case Medical History

• Past Medical History
• Pulmonary tuberculosis, treated with multi-drug
  therapy two years prior to admission patient has
  had subsequent chest radiographs documented as
  normal. One TB-related hospitalization, but no
  surgeries.
• Family History
• Uncle with positive PPD, treated with INH x past
  6 months
• Social History
• Traveled to Mexico three weeks prior to
  admission. Denied insect bites, kitten exposure,
  or consumption of raw eggs, meat, or
  unpasteurized dairy products. Denied sexual
  activity or recreational drug use drinks alcohol
  with friends on weekends.
• Review of Systems
• Denied fever, night sweats, weight loss, cough,
  rashes, or gastrointestinal symptoms

6
Case Physical Exam

• General afebrile, well-appearing adolescent
  male
• HEENT normal, no lymphadenopathy
• Cor normal, no murmurs, gallops, or rubs
• Lungs fair air entry bilaterally, no crackles
  or wheezes
• Abdomen nontender, no masses or
  hepatosplenomegaly
• Neuro nonfocal
• Extremities swelling and mild erythema at the
  posterior aspect of the distal right humerus
  tenderness to palpation along the soft tissues of
  the elbow, but no definite point tenderness.
  Decreased range of motion on flexion/extension,
  but full pronation/supination. The fingers were
  warm with intact strength and sensation.
• Skin no rashes, abrasions or lesions, or insect
  bites noted

7
Case Initial Labs

• CBC WBC 3.8 (differential of 39 neutrophils,
  45 lymphs, 14 monos, 1 eos, 1 basos).
  Hematocrit and platelet count were normal
• Chemistries and urinalysis were normal
• ESR 38 ? 48 mm/h (elevated)
• CRP 8 mg/L (elevated)
• Blood culture was drawn at time of admission
• Chest radiograph normal, with no infiltrates or
  hilar adenopathy

8
Case Differential Diagnosis

• The differential diagnosis of this patient with
  right elbow swelling included
• Infectious etiologies involving the various
  anatomic structures of the arm, i.e.
  osteomyelitis, septic arthritis, post-infectious
  transient synovitis, bursitis, myositis,
  cellulitis, or even extrapulmonary tuberculosis
  (given the patients history of treated pulmonary
  tuberculosis)
• Hematologic or solid organ malignancy, such as
  Ewings or osteosarcoma

9
Case Initial Studies

• Right elbow radiographs were normal, with no
  fracture, lytic lesions, or foreign bodies
• MRI of the right upper extremity was negative for
  osteomyelitis, myositis, synovitis, joint
  effusions, or other fluid collections. It did
  demonstrate soft tissue swelling at the region
  appreciated on clinical exam.

10
Case Paradigm Shift

• The patients elbow swelling resolved within one
  week without initiation of specific therapy.
  However, the patient was observed in the hospital
  to have daily spiking fevers to as high as 104.3
  Farenheit.
• As the patient remained well-appearing, he was
  not started on empiric antibiotics. However,
  these documented inpatient temperatures prompted
  a diagnostic workup for fever of unknown origin.
• These further infectious, immunologic, and
  rheumatologic studies returned negative,
  including
• negative viral cultures, EBV/CMV/HIV/parvovirus/in
  fluenza titers, chlamydia/gonorrhea cultures,
  hepatitis panel and
• normal ANA, RF, immunoglobulins, and complement
  levels.

11
Case Further Diagnostics

• On further questioning, the patient recalled
  ingesting unpasteurized cheese during his recent
  visit to Mexico.
• A suspicion for Brucella infection was
  entertained, and the patients blood was drawn
  for aerobic/anaerobic cultures to be held for at
  least 21 days given the fastidiousness of the
  suspected organism.
• The patient was treated empirically with
  doxycycline and rifampin pending culture results.
  
• Cultures grew pleomorphic gram negative
  coccobacilli, identified as Brucella melitensis.

12
Case Treatment and Follow-up

• The patient was discharged home to complete 6
  weeks of oral antimicrobial therapy with
  doxycycline rifampin.
• He continued to experience intermittent right
  elbow pain therefore, a three-phase bone scan
  was performed one month after initiation of
  therapy. It was abnormal and showed suspicion
  for right distal humeral osteomyelitis.
• Therefore, the patient was continued on
  antibiotic therapy for brucella osteomyelitis
• With follow-up at two months, his ESR and CRP had
  fallen to normal (3 mm/hr and lt0.02 mg/dL,
  respectively)

13
Brucellosis - Epidemiology

• Also known as Malta fever, undulant fever, or
  Bang disease
• Reported annual incidence in the United States
  range from 0.01 to 200 per 100,000
• Although not endemic in the US, brucellosis
  continues to be a common zoonotic infection in
  other countries (Mediterranean, Middle East,
  North and East Africa, India, Mexico, Central and
  South America)
• Animal reservoirs cattle, dogs, swine, goats and
  sheep
• Four species b. mellitensis is the most virulent
  in humans
• Transmission primarily via infect
  (non-pasteurized) dairy products may also be
  transmitted via aerosol or skin abrasions

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Brucellosis Clinical Manifestations

• Nonspecific symptoms (fever, sweats, malaise,
  arthralgias, back pain, headache)
• Isolated splenomegaly (51)
• Osteoarticular involvement (42)
• Cervical lymphadenitis (31)
• Hepatomegaly (25)
• other case reports of Neuro-Brucellosis,
  endocarditis, glomerulonephritis, epididymitis,
  and breast abscess

15
Brucellosis Diagnosis and Management

• Diagnosis
• Cultures (gold standard, but slow growth of the
  organism may delay the definitive diagnosis)
• serologic titers (gt95 of patients have titers
  gt1160 at the time of positive cultures)
• Others PCRs, ELISA
• Management
• Choice of antibiotic regimen dual therapy
  combination of doxycycline and rifampin,
  streptomycin, or gentamicin (for severe systemic
  disease)
• Duration of therapy 6-8 weeks, depending on
  clinical, serologic, and inflammatory marker
  response

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Conclusions

• Due to the nonspecific and sometimes misleading
  clinical presentations of brucella infection, it
  is important to have a high index of suspicion
  for this disease when evaluating pediatric
  patients for fever of unknown origin, especially
  those with potential risk factors such as travel
  to endemic regions
• More rapid diagnosis of brucellosis is aided by
  new advances in laboratory testing methods
• Optimal treatment regimens are still being
  investigated

17
References

• Al Dahouk S, Tomaso H, et al. Identification of
  brucella species and biotypes using PCR-RFLP.
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• Andriopoulos P, Tsironi M, et al. Acute
  Brucellosis Presentation, Diagnosis, and
  Treatment of 144 cases. Int J Infect Dis, 2006
  Apr 29.
• Gur A, Geyik MF, et al. Complications of
  brucellosis in different age groups a study of
  283 cases in southeastern Anatolia of Turkey.
  Yonsei Med J 2003443344.
• Memish ZA and HH Balkhy. Brucellosis and
  international travel, J Travel Med 11 2004
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• Pappas G, Solera J, et al. New Approaches to the
  antibiotic treatment of brucellosis. Int J
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