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A Complex Parapneumonic Pleural Effusion Presenting with Back Spasms
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A6695 - A Complex Parapneumonic Pleural Effusion Presenting with Back Spasms
Author Block: A. Shallal, M. Reaume, L. Yadav, M. Olken; Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, United States.
Back spasms are frequently observed in the outpatient setting, and the diagnosis is most commonly musculoskeletal in nature. However, we present a case of back spasm as the only presenting symptom of a complex parapneumonic effusion with significant hypoxia requiring intensive care treatment.A 71-year-old male with a history of asthma and recent right hip replacement presented to the emergency department (ED) with severe lower back spasms for one week. His primary care provider felt it was likely secondary to post-operative deconditioning, and prescribed muscle relaxants and opioids. In spite of this, the spasms progressively worsened and were eventually accompanied by dyspnea and pleuritic chest pain. In ED, he was found to be tachypneic, tachycardic, and hypoxic, with oxygen saturation of 85% on ambient air. Physical examination was remarkable for spasmodic and tense paraspinal muscles, as well as diminished air entry and dullness on percussion in the right base. Labs were remarkable for WBC count of 22 and procalcitonin of 0.48. A computed tomography (CT) of the chest, abdomen, and pelvis showed a 5.5cm soft tissue lesion in the right lung base with surrounding atelectasis and large, loculated right sided pleural effusion with prominent lymphadenopathy. He required BiPAP for his hypoxia and thus was admitted to the intensive care unit (ICU). He underwent CT-guided right chest tube placement by interventional radiology (IR) the following day, and fluid analysis was consistent with an exudative effusion. Culture results were negative for fungal, anaerobic, and aerobic microbes. His back spasms significantly improved with drainage of fluid. A repeat CT chest showed complete resolution of the soft tissue mass with persistent atelectasis and small residual effusion. He was discharged on hospital day five with four-week therapy of augmentin and subsequently made a complete recovery.The differential diagnosis for back spasms is broad, and includes musculoskeletal causes, electrolyte imbalances, as well as neurologic causes. A review of published literature yielded no other documented cases of this obscure presenting symptom for a pleural effusion. This case thus highlights the importance of a thorough physical examination in patients presenting with back spasms, as this patient had classic signs of pleural effusion. In addition, this case highlights the importance of including structures of the thoracic cavity when considering the differential diagnosis for back spasms.
Author Block: A. Shallal, M. Reaume, L. Yadav, M. Olken; Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, United States.
Back spasms are frequently observed in the outpatient setting, and the diagnosis is most commonly musculoskeletal in nature. However, we present a case of back spasm as the only presenting symptom of a complex parapneumonic effusion with significant hypoxia requiring intensive care treatment.A 71-year-old male with a history of asthma and recent right hip replacement presented to the emergency department (ED) with severe lower back spasms for one week. His primary care provider felt it was likely secondary to post-operative deconditioning, and prescribed muscle relaxants and opioids. In spite of this, the spasms progressively worsened and were eventually accompanied by dyspnea and pleuritic chest pain. In ED, he was found to be tachypneic, tachycardic, and hypoxic, with oxygen saturation of 85% on ambient air. Physical examination was remarkable for spasmodic and tense paraspinal muscles, as well as diminished air entry and dullness on percussion in the right base. Labs were remarkable for WBC count of 22 and procalcitonin of 0.48. A computed tomography (CT) of the chest, abdomen, and pelvis showed a 5.5cm soft tissue lesion in the right lung base with surrounding atelectasis and large, loculated right sided pleural effusion with prominent lymphadenopathy. He required BiPAP for his hypoxia and thus was admitted to the intensive care unit (ICU). He underwent CT-guided right chest tube placement by interventional radiology (IR) the following day, and fluid analysis was consistent with an exudative effusion. Culture results were negative for fungal, anaerobic, and aerobic microbes. His back spasms significantly improved with drainage of fluid. A repeat CT chest showed complete resolution of the soft tissue mass with persistent atelectasis and small residual effusion. He was discharged on hospital day five with four-week therapy of augmentin and subsequently made a complete recovery.The differential diagnosis for back spasms is broad, and includes musculoskeletal causes, electrolyte imbalances, as well as neurologic causes. A review of published literature yielded no other documented cases of this obscure presenting symptom for a pleural effusion. This case thus highlights the importance of a thorough physical examination in patients presenting with back spasms, as this patient had classic signs of pleural effusion. In addition, this case highlights the importance of including structures of the thoracic cavity when considering the differential diagnosis for back spasms.
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