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BACKGROUND
A 47-year-old man presents to the emergency department (ED) with severe left shoulder pain and intermittent fevers for 1 week. He reports diffuse joint discomfort, most notably in his left shoulder, and in his toes. He was examined in the ED yesterday. Acetaminophen-hydrocodone was prescribed but provided no relief. He denies using injected drugs. His wife adds that they were "getting a lot of fleabites at home." Although their dog died from "old age" about 3 weeks ago, they still have fleas in the house. She wants to know if rats can carry fleas because they bought a pet rat about 2 weeks ago.
On physical examination, the patient has a fever (temperature, 101.3°F [38.5°C]), but the rest of his vital signs are normal. His left wrist is resting between opened buttons of his shirt as a makeshift sling, and he demonstrates clinically significant guarding of the left shoulder. His shoulder is tender but not red or swollen. He also has a maculopapular rash on his legs (see Image 1) without distinct lesions suggestive of insect bites. He has a well-healed bite mark on his left index finger; the area is not tender or erythematous (see Image 2). Other physical findings are unremarkable.
The patient's blood work is notable only for a WBC of 15.7 X 109/L. A CT scan of the shoulder is obtained to evaluate for an effusion and a possible septic joint. No effusion is present, but calcium deposits are seen in the bicipital groove.
Is calcific tendonitis consistent with this patient's presentation? What is the etiology of the patient's fever?
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Hint
The radiographic finding is a red herring.
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Author:
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D. Brady Pregerson, MD,
Attending Physician,
Department of Emergency Medicine,
Cedars Sinai Medical Center;
Author,
Quick Essentials: Emergency Medicine, 2nd Edition and
A to Z Pharmacopoeia (www.ERpocketbooks.com) |
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eMedicine
Editor:
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Erik D. Schraga, MD,
Department of Emergency Medicine,
Kaiser Permanente,
Santa Clara Medical Center, Calif
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