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Fever and Joint Pain

UNFINISHED CASE: COME BACK LATER 

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History of Present Illness:

A 32-year-old male presents to the ED for one day of fever up to 103.5 and joint pains affecting both knees and both ankles.  He is also having a generalized headache. About 2 weeks ago he presented for dysuria and was treated for a possible STD but both chlamydia and GC tests were negative.  He denies any vomiting, cough, sore throat, rash or diarrhea but is feeling fatigued.

Vital Signs & Physical Exam:

Vital signs are normal except for a temp of 100.4.  Physical exam is normal except for slight pain when moving eyes to side and a positive jolt sign.  Examination of the joints is normal.

Initial Differential Diagnosis:

  • Viral syndrome
  • Meningitis
  • Septic Arthritis
  • Disseminated GC
  • HIV
  • HSV

Initial Diagnostic Testing:

  • CBC was completely normal but there was a high normal WBC and PMN count
  • BMP was normal

QUESTIONS:

  1. What is a JOLT SIGN? 
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image image show?  Jolt sign is an important exam test that involves shaking the head with rapid rotation.  It is positive if it causes pain.  In an alert patient it is probably about 99% sensitive and 50% specific for meningitis.
  2. What should you do next?  An LP which showed 3 RBC and 300 WBC, mostly lymphs, a protein of 110 and a glucose of 55 (serum level was 100).  He was treated for possible herpes meningitis.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: CSF HSV2 PCR was positive.  A brain MRI was done, which was fortunately normal.  It is important to know that HSV meningitis, though famous for causing elevated RBC’s in the CSF only causes this in about 50% of patients.  Also only ~30% of patients with HSV meningitis report a prior history of genital lesions.

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