Lab Studies:
Labs August 2016 <br>CBC: WBC 6.7, HGB 12.9, HCT 39, Plt 206 <br>ESR 38 <br>CRP 0.1 <br>RF 6.9 <br>HLA-B27 neg. <br> <br>Labs December 2016 <br>ESR 15 <br>CRP less than 0.1 <br>Bartonella Henselae Ab less than 1:64 <br>Brucella total Ab less than 1:20 <br>Coccidioides serology neg <br>Q-fever Ab IgG neg <br>Quantiferon TB Gold neg. <br> <br>Labs March 2017 <br>CBC: WBC 10.4, HGB 13.5, HCT 40.3, Plt 238 <br>RF less than 10 <br>HLA-B27 neg. <br> <br>CMP: Na 138, K 4.7, Cl 102. CO2 26, BUN 12, Cr 0.57, Glucose 89 <br>Ca 9.7 <br>LFTs: TP 7.6, Alb 4.1, AST 29, ALT 19, Tbili 0.4, Dbili NR, ALP 518 <br>ESR 9 <br>CRP less than 0.1

Other Studies:
XRs AP pelvis / SI joint / LS spine (12/2015) - unremarkable <a href="CaseStudyImages/CS1AnUnusualCaseofBu-680.jpg" title="Case Photo #1" data-lity><b>Case Photo #1</b></a> <br> <br>MR Pelvis wo contrast (12/2015) - SIJ intense edema into left hemisacrum/ilium with left SI effusion, diastasis. 1.6 cm lobulated hematoma anterior to the SIJ with apex at SIJ anterior margin. <a href="CaseStudyImages/CS2CS1AnUnusualCaseo-680.jpg" title="Case Photo #2" data-lity><b>Case Photo #2</b></a> <br> <br>Repeat T/L/S-spine XR (3/2016) - unremarkable spine but with SI joint sclerosis. <a href="CaseStudyImages/CS3CS2CS1AnUnusualCa-680.jpg" title="Case Photo #3" data-lity><b>Case Photo #3</b></a> <br> <br>Pelvis XR (9/2016) - increased sclerosis, erosive/destructive changes of left SIJ. concern for inflammatory/infectious erosive process. <br> <br>MR pelvis w/wo contrast (10/2016) - osseous sclerosis, widening, erosive changes, synovitis of left SI joint. adjacent rim-enhancing fluid collection. concern for septic arthritis, intraosseous abscess, adjacent osteomyelitis in left sacral ala. <a href="CaseStudyImages/CS5CS4CS3CS2CS1AnUnu-680.jpg" title="Case Photo #5" data-lity><b>Case Photo #5</b></a> <br> <br>Left SI joint biopsy pathology (2/2017) - bone marrow fibrosis, chronic inflammation. suggestive of a reactive/inflammatory process. <br> <br>MICRO - <br>GS = 2+ RBC, no WBC/organisms <br> <br>Bacterial culture - <br>+1 colony P acnes <br>+S epidermidis in broth only <br>Fungal cx felt to be contaminants <br> <br>AFB smear, culture neg.

Consultations:
Orthopedic surgery - did not recommend surgical intervention <br> <br>Pediatric Infectious Disease - recommended the above serologies and CT-guided biopsy and aspiration

Click here to continue. Challenge yourself by writing down a revised, working diagnosis before moving to the next slide.