Lab Studies:
Labs August 2016
CBC: WBC 6.7, HGB 12.9, HCT 39, Plt 206
ESR 38
CRP 0.1
RF 6.9
HLA-B27 neg.

Labs December 2016
ESR 15
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
HLA-B27 neg.

CMP: Na 138, K 4.7, Cl 102. CO2 26, BUN 12, Cr 0.57, Glucose 89
Ca 9.7
LFTs: TP 7.6, Alb 4.1, AST 29, ALT 19, Tbili 0.4, Dbili NR, ALP 518
ESR 9
CRP less than 0.1

Other Studies:
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.

MICRO -
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.

Consultations:
Orthopedic surgery - did not recommend surgical intervention

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.