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Case 33
An 35 year-old homeless woman began to experience sharp upper-back pain yesterday, and today feels
feverish and sweaty. She reports that she uses IV heroin and methamphetamine regularly–she does not
share needles, but does reuse them. She has not noticed any weakness or numbness, but finds that she
has to urinate more frequently than normal today. On exam, her temperature is 39.4 and pulse is 120.
She has focal spinal tenderness to percussion at T1. Right-sided foot-taps are slightly slowed and right
patellar and Achilles reflexes are 3+ compared to 2+ on the left, but her neurologic exam is otherwise
normal.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?
Case 33
An 35 year-old homeless woman began to experience sharp upper-back pain yesterday, and today feels
feverish and sweaty. She reports that she uses IV heroin and methamphetamine regularly–she does not
share needles, but does reuse them. She has not noticed any weakness or numbness, but finds that she
has to urinate more frequently than normal today. On exam, her temperature is 39.4 and pulse is 120.
She has focal spinal tenderness to percussion at T1. Right-sided foot-taps are slightly slowed and right
patellar and Achilles reflexes are 3+ compared to 2+ on the left, but her neurologic exam is otherwise
normal.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?