Case 2: Fever and Back Pain in 13-year-old Girl

Presentation

A previously healthy 13-year-old girl who plays hockey presents with fever of 6 days’ duration accompanied by lower back pain and generalized myalgia. She initially went to an urgent care facility, where she had normal findings on urinalysis and a negative flu antigen test. She was diagnosed with a viral illness, but her symptoms persisted. Today she is experiencing a severe throbbing frontal headache and nausea. She has no history of furuncles, intravenous drug use, or recent blunt spinal trauma. Review of symptoms is negative.

Initial vital signs show temperature of 99.2°F (37.3°C), heart rate of 130 beats/min, and blood pressure of 126/67 mm Hg. Physical examination of the girl, who is sitting uncomfortably in bed, reveals localized tenderness to palpation in the lower lumbar region. A nonradiating grade 2/6 systolic ejection murmur is best heard at the apex. There are no skin lesions or rashes. The patient is alert and oriented to person, place, and time, with intact short- and long-term memory. Cranial nerves II through XII are intact. Strength is 5/5 in all extremities, with normal tone and sensations to pain, temperature, and light touch. She has normal gait with intact finger-to-nose touch and aligned ankle-over-tibia. Her deep tendon reflexes are 2+ throughout and Brudzinski and Kernig signs are both negative.

Laboratory evaluation reveals a white blood cell (WBC) count of 10,200/μL (10.2 × 10⁹/L) with 79.9% …