This 43 yr female, from affluent class, came to for second opinion 5month ago. She was suffering from bachache since last two month. No fever,no loss of apetite, no weight loss and pain was localised to lower back. She was seen by neurologist, orthopedics, rheumatologist, spine surgeons & OB&G. CBC,CT & MRI were normal. ESR 35.Reason for my opinoin was non relieving pain by all measures and she was advised ovarian cyst surgery for pain. As I was I was not convinced with small folicular cyst and pain relation I asked to go to other OB&G, where he said this may due to LS joint TB. As pateint has local tenderness. He send patient back to me. She had local tenderness. I got her montoux, which was positive (20*20). Usg neck abdomen normal. Repeat ESR-40. CRP 32.
I was of the opinion to start AKT. But patient wanted confirmation, so I advised PET-CT, which showed increased uptake in LS Joint, pancreas and small lesion at Right lung apex area. To get bug and culture it I advised to go LS joint biopsy and cs or navigation-MR guided needle aspiration at clevland USA. Patient went to spine surgeon for biposy where he not only advised against biposy but said it is nothing . Got HLADR27, brucella and ANA profile which was negative. He advised patient to go to ID. As patient was from very affluent class well to lots of supersepecialst ,they took opinion from many concerned superspecialist and everyone advised against AKT.
She was put on NEOCOXIA AND MINOCYCLINE THINKING that it is PID and even PET CT , MONTOUX , ESR AND CRP ALL WERE IGNORED. She GOT SYMPTOMATICALLY BETTER.
After 6 month they came back to me with more sevre pain, fever low grade and incresed CRP ,ESR. This time same ID person advised that she should be given trail. Repeat HRCT -THORAX ,increased lung invlovement, medustinal LN positive. Now last 15 day she is on full AKT.
Though I persued this patient so much and was so confident for dx which I could see well before time, but was not endorsed by other seniors so treatment got delayed for 6 moth only.
