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A 15 year old boy was seen at a primary care office because of six days of documented fever, slight cough, and back pain. It was in the middle of March near the end of busy flu season. The chest examination was normal. The physician thought that it might be myalgia from a viral infection. However, to be on the safe side, he ordered a CBC which turned out to be normal.
Two weeks later, the boy was back at to see the same physician. This time he is complaining that the achiness in this chest has become persistent upon coughing or yawning. The fever from last visit did not come back. Lung examination showed a prolonged expiratory phase which made the physician question the possibility of asthma that lead him to prescribed albuterol inhaler.
Another two weeks passed. The teenager was seen by a partner of the first physician because of left-sided chest pain that was radiating to the back. He was still afebrile and he reported that the albuterol seem to help. However, his chest pain seem to be worse in the past several days. He had tenderness at the left sternal border and to the left of the midthoracic spines. His lungs were clear and there was no friction rub. The second physician considered the four “Ps”: pneumonia, pericarditis, pneumothorax, and pleuritic pain and requested CBC and ESR. Both showed normal results, thought that the problem is costochondritis and prescribed ibupropen.
A few days later, the first physician called to report the normal CBC and ESR. His parents said that he seems better from the ibupropen.
Six weeks later, the boy is back! The back pain is worse and localized at the thoracic spines. This time he has fever. He has seen a chiropractor once a week without relieving the back pain.
A lab test and imaging was ordered and clinched the diagnosis.
Answer: Diskitis; Osteomyelitis
Reference: Contemporary Pediatrics, October 2002, page 25, “Cough and achiness in an adolescent: The boy’s back again!”
Leo Leonidas, MD, FAAP
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