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A 14yearold male with selfresolving right elbow swelling


Chest radiograph normal, with no infiltrates or hilar adenopathy. Case: Differential Diagnosis ... Right elbow radiographs were normal, with no fracture, lytic ... – PowerPoint PPT presentation

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Title: A 14yearold male with selfresolving right elbow swelling

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
  • Houston, Texas

  • 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.

Background / Objectives
  • This case illustrates the potential for chimeric
    / varied presentations of a known zoonotic
  • 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

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
  • Somewhat relieved with ibuprofen
  • Aside from the recent phlebotomy history, the
    patient reported no other trauma to the arm.

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
  • 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

Case Physical Exam
  • General afebrile, well-appearing adolescent
  • 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
  • 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

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

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
  • Hematologic or solid organ malignancy, such as
    Ewings or osteosarcoma

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.

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
  • 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,
  • negative viral cultures, EBV/CMV/HIV/parvovirus/in
    fluenza titers, chlamydia/gonorrhea cultures,
    hepatitis panel and
  • normal ANA, RF, immunoglobulins, and complement

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.

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,

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
  • 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

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

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
  • Duration of therapy 6-8 weeks, depending on
    clinical, serologic, and inflammatory marker

  • 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

  • Al Dahouk S, Tomaso H, et al. Identification of
    brucella species and biotypes using PCR-RFLP.
    Crit Rev Microbiol. 200531(4)191-6.
  • 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
  • Pappas G, Solera J, et al. New Approaches to the
    antibiotic treatment of brucellosis. Int J
    Antimicrob Agents. 2005 Aug, 26(2)101-5.
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