Labs August 2016
CBC: WBC 6.7, HGB 12.9, HCT 39, Plt 206
Labs December 2016
CRP less than 0.1
Bartonella Henselae Ab less than 1:64
Brucella total Ab less than 1:20
Coccidioides serology neg
Q-fever Ab IgG neg
Quantiferon TB Gold neg.
Labs March 2017
CBC: WBC 10.4, HGB 13.5, HCT 40.3, Plt 238
RF less than 10
CMP: Na 138, K 4.7, Cl 102. CO2 26, BUN 12, Cr 0.57, Glucose 89
LFTs: TP 7.6, Alb 4.1, AST 29, ALT 19, Tbili 0.4, Dbili NR, ALP 518
CRP less than 0.1
XRs AP pelvis / SI joint / LS spine (12/2015) - unremarkable Case Photo #1
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. Case Photo #2
Repeat T/L/S-spine XR (3/2016) - unremarkable spine but with SI joint sclerosis. Case Photo #3
Pelvis XR (9/2016) - increased sclerosis, erosive/destructive changes of left SIJ. concern for inflammatory/infectious erosive process.
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. Case Photo #5
Left SI joint biopsy pathology (2/2017) - bone marrow fibrosis, chronic inflammation. suggestive of a reactive/inflammatory process.
GS = 2+ RBC, no WBC/organisms
Bacterial culture -
+1 colony P acnes
+S epidermidis in broth only
Fungal cx felt to be contaminants
AFB smear, culture neg.
Orthopedic surgery - did not recommend surgical intervention
Pediatric Infectious Disease - recommended the above serologies and CT-guided biopsy and aspiration
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