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A 41 year old man with low

back pain, fever and cough


Presented by
Dr. Naima Akhter Dina
HMO
Department of Physical Medicine &
Rehabilitation
Particulars of the patient:
Name : Md. Ishaq Ali
Age : 41 years
Sex : Male
Religion : Islam
Marital status : Married
Occupation : Farmhouse worker
Address : Vill: Mohela, P.S: Kalihati
District : Tangail
Date of Admission : 16.09.13
Date of Examination : 16.09.13





Chief Complaints:

1. Low back pain for 2 months

2. Fever for 5 months

3. Cough for 5 months




History of Present illness:
According to the statement of the
patient he developed low back pain for 2
months which was sudden onset, dull
aching in nature, moderate to severe in
intensity, localized to low back region,
persistent, relieved by walking,
associated with morning stiffness (>1
hr) .He gives no H/O joint pain and
swelling, headache, redness of eye,
bowel/ bladder disturbances.

Present illness (cont)

He also complained of fever and cough
for 5 months. Initially for 1 month the
fever was low grade, occurred at night,
subsided by antipyretic. Then after a
afebrile period of 15 days, he again
developed fever which was recurrent
episodic, high grade, intermittent ( 2
times rise/ day, last for 3 hrs), came with
chills and rigor, subsided by profuse
sweating.
Present illness (cont)
The highest recorded temp was 104F.
The duration of febrile and afebrile period
was about 15 days which came
alternatively. Fever was associated with
anorexia, nausea, vomiting, malaise and
fatigue.
Present illness (cont)
He also complained of dry cough for the
same duration which was persistent, more
at night causing sleep disturbance. He
gives no H/O blood with cough, chest pain,
breathlessness or significant weight loss.

Present illness (cont)
He is normotensive, non diabetic & non
asthmatic.
For these above complaints he was seen
by Doctor in KSA and treated accordingly
on 8.09.13 and now he was admitted
in this hospital for better management.
History of Past illness:


He had history of jaundice 8 years back
and brucellosis 1 year back which was
diagnosed in KSA and he was treated with
Cap. Doxycycline (100mg) twice daily and
inj. Streptomycin I/M once daily for 21
days. He had no H/O TB, IHD or any
surgical interventions.




Drug History:

Patient was taking Cap. Doxycycline
100mg twice daily, Cap. Rifampicine
150mg once daily, antipyretic and
analgesic for his illness.

Family History:
He has 2 brothers and he lives with his
wife and 2 sons. None of his family
members have same type of illness.





Socio-Economic History:

He is the only earning member of his
family, lived in KSA for last 9 years where
he worked as a farmhouse worker ( goat-
sheep farm) and earned 25 thousands Tk/
month. In KSA, he lived in a tin-shed
house, drank mineral water and did not
use sanitary latrine.
Personal History:
He is non-smoker, non-alcoholic & does
not take betel nut. He is habituated to
normal Bangladeshi and Arabian diet. He
had no history of sexual exposure and no
history of contact with TB patient.

Immunization History :
He is not immunized as per EPI schedule.
General Examination:
Appearance : anxious
Body build : average
Co-operation : co-operative
Decubitus : on choice
Nutritional status : average
Height : 5 ft
Weight : 55 kg
BMI : 24.44 kg/m
2


















General Examination ( cont)
Anaemia : mild
Jaundice : absent
Cyanosis : absent
Oedema : absent
Dehydration : absent
Clubbing : absent
Koilonychia : absent
Leuconychia : absent

General Examination ( cont)

Thyroid gland : not enlarged
Neck vein : not engorged
Skin condition : normal
Hair distribution : normal
Bony tenderness : absent
Lymph nodes : not palpable
BCG mark : present






General Examination ( cont)
Pulse : 72 / min.
Blood Pressure : 110 / 70 mm of Hg
Temperature : 98
0
F
Resp. rate : 18 / min.

Musculoskeletal System
examination:

Gait : normal

Arms : normal

Legs : normal







Spines:
look - no spinal deformity
- no swelling
- no muscle wasting
feel - tenderness over L5-S1
region and over left
sacroiliac
joint present ( grade II )
-step sign : negative







move -flexion : restricted
-extension : restricted
-lateral flexion : restricted
Special tests :
Modified Schobers test : positive(4 cm)
Finger -Floor distance : positive(20 cm)
Wall -Occiput distance : 0 cm
FABER test : negative
Gaenslens test : negative

Special tests :

Pelvic compression test : negative
Pelvic distraction test : negative
Straight leg raising test : 70 degree
(both sides)
Total chest expansion : restricted
(2.5 cm)

Respiratory system examination:
Inspection:
Chest shape : normal
Chest movement : bilaterally
symmetrical
Visible pulsation : absent
Suprasternal, intercostal
or subcostal indrawing : absent






Palpation
Position of trachea : central
Position of apex beat : left 5
th
ICS, just
medial
to mid clavicular line
Chest expansion : symmetrical
Total chest expansion : restricted (2.5cm)
Vocal fremitus : normal
Percussion:
Percussion note : resonant
Auscultation:
Breath sound : vesicular with
no added sound
Vocal resonance : normal
Alimentary system examination:

Oral cavity
Lips, tongue, palate, gum & vestibule
are normal.

Abdomen proper
Inspection:
Shape of the abdomen : normal
Flanks : not full
Umbilicus : centrally placed,
inverted
Skin condition : normal



Superficial palpation
Temperature : normal
Tenderness : absent
Muscle guard : absent
Muscle rigidity : absent

Deep palpation:
Liver : not palpable
Spleen : not palpable
Kidney : not ballotable
Urinary bladder : not palpable
Fluid thrill : absent
External genitalia : normal

Percussion:
Percussion note : tympanitic

Auscultation:
Bowel sound : present
Nervous system examination:

Higher psychic function : normal
Cranial nerves : intact
Motor system : normal
Sensory system : normal
Sign of menengial irritation : absent
Cerebeller sign : absent

Cardiovascular system
examination:
Inspection:
Chest shape : normal
Apical impulse : absent
Scar mark : absent
Palpation:
Position of apex beat : left 5
th
ICS, just medial
to mid clavicular line
Thrill : absent
Left parasternal heave: absent
Palpable P2 : absent










Percussion:
Area of cardiac dullness : normal


Auscultation:
1
st
and 2
nd
Heart sound : present
Added sound : absent
Salient features
Md. Ishaq Ali, 41 years, male, muslim,
married, non-smoker, normotensive, non-
diabetic, non asthmatic, farmhouse
worker in KSA for last 9 years, hailing
from Tangail, admitted into this hospital
through OPD on 16/09/13 with the
complaints of low back pain for 2 months,
fever and cough for 5 months.

Salient features ( cont )
The patient developed low back pain for 2
months which was sudden onset, dull aching
in nature, moderate to severe in intensity,
localized to low back region, persistent,
relieved by walking, associated with morning
stiffness (>1 hr).
He gives no H/O joint pain and swelling,
headache, redness of eye, bowel/ bladder
disturbances.
Salient features ( cont)

He also complained of fever and cough
for 5 months. Initially for 1 month the
fever was low grade, occurred at night,
subsided by antipyretic. Then after a
afebrile period of 15 days, he again
developed fever which was recurrent
episodic, high grade, intermittent ( 2
times rise/ day, last for 3 hrs), came with
chills and rigor, subsided by profuse
sweating.


Salient features ( cont)
The highest recorded temp was 104F.
The duration of febrile and afebrile period
was about 15 days which came
alternatively. Fever was associated with
anorexia, nausea, vomiting, malaise and
fatigue.
Salient features ( cont)
He also complained of dry cough for the
same duration which was persistent, more
at night causing sleep disturbance. He
gives no H/O haemoptysis, chest pain,
breathlessness or significant weight loss.



Salient features ( cont)
For these above complaints he was
treated with Cap. Doxycycline 100mg
twice daily and Cap. Rifampicine 150mg
once daily in KSA.
Salient features ( cont)
He had history of jaundice 8 years back
and brucellosis 1 year back which was
diagnosed in KSA and he was treated
with Cap. Doxycycline (100mg) twice
daily and inj. Streptomycin I/M once daily
for 21 days. He had no H/O TB or contact
with TB patient.


Salient features ( cont)
On examination, patient is anxious, mildly
anaemic, lymph nodes are not palpable,
his pulse- 72 / min, blood pressure- 110 /
70 mm of Hg, temperature- 98
0
F, no
deformity of spine, grade II tenderness
present over L5-S1 region and left
sacroiliac joint, all movements of spine
restricted, Modified Schobers test:
positive (4 cm), total chest expansion:
restricted (2.5 cm), no organomegaly.

Provisional diagnosis


?
Provisional diagnosis

Brucellar Spondylitis
Differential diagnosis
Recurrent flue like illness with
spondyloarthopathy

Tuberculosis of spine

Undifferentiated Spondyloarthopathy

Non specific low back pain with
recurrent flue like illness






CBC
1
st

hospital
day
16.09.13
8
th

hospital
day
23.09.13
13
th

hospital
day
28.09.13
Hb%(gm/dl) 10.3 12.8 13.9
ESR (mm in 1
st
hr) 140 65 70
WBC(/cmm) 5000 2800 3000
Neutrophil % 65 24 18
Lymphocyte% 30 70 68
Eosinophil % 03 04 02
Monocyte % 02 10
Myelocyte% 02
Platelet
count(/cmm)
170000 150000
Investigations (cont)
PBF(23.09.13):
RBCs - mild rouleaux formation with
anisochromia and anisocytosis
WBCs - are mature with above count and
distribution
Platelets - are normal

Comment- Leucopenia with high ESR
Investigations (cont)
PBF(28.09.13):
RBCs - mild rouleaux formation with
anisochromia and anisocytosis
WBCs - are mature with above count and
distribution
Platelets - are normal

Comment- Leucopenia with high ESR
Investigations (cont)
Urine R/M/E : normal study
S. creatinine : 0.7 mg/dl
FBS : 76 mg/dl
2 hrs ABF : 105 mg/dl
S. billirubin : 0.4 mg/dl
SGPT : 36 U/L
HBsAg : non-reactive
Anti-HCV : non-reactive

Investigations (cont)
MT test : negative
Sputum for AFB : negative
Sputum for Gram stain : both extracellular
and intracellular
Gram negative
diplo cocci is
present
Sputum for C/S : no growth

Investigations (cont)


Investigations (cont)
USG of whole abdomen : Normal study

ECG : Normal study

Echocardiography : Normal study

Chest X-ray ( P/A view) : normal study





Chest X-ray ( P/A view)
Investigations (cont)
X-ray Lumbo-sacral spine
(A/P & lateral view) : grade I
spondylolisthesis
of L5 over S1 with
lumbar spondylosis
X-ray both SI joints
(Oblique view) : normal study



X-ray Lumbo-sacral spine
X-ray both SI joints (Oblique view)
MRI of D/L spine & both SI joints:

-degenerative disc & spine disease
- L4-L5: disc bulging with corresponding
thecal sac indentation
- L5-S1: central & both para central disc
protrusion with corresponding thecal sac
indentation & bilateral foraminal narrowing.
MRI of D/L spine
MRI of D/L spine
Bone marrow study:
- Average cellular marrow with normal M:E ratio
- Erythropoiesis is active and normoblatic
- Granulopoiesis is also active and maturing
into segmented forms
- Megakaryocytes are normal
- Lymphocytes and plasma cells are increased
- No sign of hemophagocytosis, no granuloma,
ectopic cell or parasite is seen
Comment: Features suggestive of secondary
reactive marrow

Confirm diagnosis
Brucellar spondylitis
Management:
A. General Management:
a. Rest
b. Assurance
c. Patient education
- about disease
- about management
- about outcome
- about prevention


Management(Cont )
B. Specific management:

(Acc. to WHO) management of brucellar
spondylitis :
Cap. Doxycycline 100 mg twice daily for 6 weeks
Cap. Rifampicin 900 mg/day for 6 weeks and
Inj. Streptomycin 1 g/day IM for 3 weeks.








Management(Cont )
-Others:
Cap. Indomethacine
Cap. Omeprazole
Tab. Tolperisone
Tab. Levosulbutamol
Management(Cont )
ADL advices:
-avoid heavy lifting
-use firm mattress and single pillow
Present condition of the patient:
Symptoms:
Fever - subsided
Cough - improved
Low back pain - improved

On examination:
All movements of spine - restored
Expansibility of chest - restored

CBC (05.10.13):
Hb% - 11.0 gm/dl
ESR - 43 mm in 1
st
hr.
WBC - 4260/cmm
Neutrophil - 30.5%
Lymphocyte - 56.8%
Monocyte - 6.6%
Eosinophil - 5.9%
Basophil - 0.2%
Platelet count - 216000/ cmm
PBF (05.10.13):
RBCs - normochromic and normocytic
WBCs - are mature, total and differential
counts are within normal limit
Platelets - are normal
No MP is seen

Comment: Non - specific morphology
Follow-up:
essential for ensuring that the patient
complies with the full 6-week antibiotic
regimen
continued until the infection is cured and
laboratory findings return to reference
ranges.
to monitor the course of low back pain

Prevention:
Avoid potential sources of infection
-avoiding infected animals
-using precautions(eg, gloves and mask)when
dealing with a potentially infected animal
-avoiding potentially contaminated foods
For farmers, immunization of cattle against
the disease
For laboratory workers, maintenance of the
appropriate level of containment