The Case


5 days of intermittent fever and 2 weeks of right lower back pain


19 yo M with hx of anhydrosis and tetralogy of fallot s/p repair (at 9 mo of age) presenting with 2 weeks of continued right lower back pain and 5 days of intermittent fevers. Patient reports having fevers that have not responded to tylenol/motrin, endorses a tmax of 104F (axillary) at home. He denies associated cough, congestion, chest pain, dyspnea, abdominal pain, n/v/d, dysuria or rashes. He denies night sweats, joint swelling, oral or genital ulcers. No sick contacts or recent travel.

Patient does report having a sciatica flare for the past two weeks. He was placed on a steroid taper along with Tizanidine however symptoms have not improved and he is now only able to ambulate with crutches or uses wheelchair to get around. He endorses pain on the right lower back radiating to the right buttock and thigh. He denies trauma, numbness/tingling, saddle anesthesia, bladder and bowel retention/incontinence or similar symptoms on contralateral leg. He discontinued Tizanidine given his concern that it may have been causing his fevers. Patient had been evaluated in two ED visits prior to presentation today for back pain and given diagnosis of muscle spasms vs sciatica. Patient underwent an MRI lumbar spine as outpatient with findings consistent with multilevel disc degeneration, no other findings.

Physical Exam

Vitals: BP 142/47, HR 71, Resp 14, SpO2 100%, Temp 98.8F (Tmax in ED 101.2F)
General: aaox3, NAD
Neck: supple
CV: RRR, S1 and S2 with no murmur, radial pulse 2+, healed surgical scar
Pulm: CTAB
Abd: No tenderness or guarding, no masses or hepatosplenomegaly on palpation
MSK: no C/T/L spine tenderness; unable to bear weight with RLE; Tenderness in the proximal R thigh, R buttock
Neuro:CN intact. Motor: Bulk/tone normal; Strength 5/5 UE, LE; No pronator drift. Reflexes: Babinski sign neg; Patellar 3+ b/l, achilles 2+ b/l; No clonus. Sensation: Intact throughout. Coordination: Finger to nose normal. Gait: few steps with crutches but hesitant


CBC 11.3/12/37.1/198   76% neutrophils, 12% lymphocytes
BMP 138/3.7/99/27/13/0.77<104
LFTs AST 19, ALT 31, Alk Phos 86, t bili 0.8, d bili 0.4, albumin 3.7, total protein 7.2
CK  32
CRP 95.7
ESR 70
HIV negative
Blood Cultures pending

CXR: no pleural effusion, cardiomediastinal silhouette is unremarkable, no focal consolidation
Pelvis Xray: No acute fracture of the bony pelvis visualized


  1. What is your differential diagnosis for this case?

  2. Any other labs or imaging studies that may help you find a diagnosis?

  3. Would you get any specialist involved from the ED, if so, what consults would you obtain?