In the latest of our monthly series, Dr Henna Taimoor is asking readers to suggest what is the cause of this elderly woman’s back pain, fever and right flank pain symptoms. Put your answers in the comments. Answers to be revealed on 13 August!
This 73-year-old Asian female patient presents to you for the first time during a busy GP clinic with back pain, fever and right flank pain symptoms. Initial examination reveals discomfort in the right flank suggesting UTI and renal infection.
The patient’s urine dip is positive for leucocytes, nitrites and blood. You treat her for suspected pyelonephritis, prescribing oral cefalexin for one week and arranging review to follow up in one week.
You order baseline tests including renal function and a urine culture.
At review the next week the patient’s feverish symptoms have-resolved, while her back pain had improved It had not resolved and she is feeling quite fatigued.
The blood workup reveals a drop in haemoglobin to 98 g/dl, down from 120 g/dl a few months ago, a normal white cell count and normal renal function.
Urine culture confirms E coli sensitive to cefalexin. A repeat urine dip shows persistent non-visible haematuria blood 3+ despite the infection-having been resolved.
Looking through the patient’s notes you see she has a-past medical history of breast cancer diagnosed 15 years prior; she underwent successful wide local excision and radiotherapy followed by tamoxifen for five years.
She has no other significant past history – no history of smoking or alcohol or significant occupational exposures. However, you note she presented last year with back pain and left sided chest wall pain which were thought to be muscular and managed with analgesia by a colleague.
In view of the fatigue and anaemia, you start her on oral iron replacement for symptomatic relief, arrange tests to rule out bowel causes of anaemia and organise another follow-up appointment.
At review a few weeks later she mentions she still has symptoms of ongoing back pain fatigue and mainly right flank/right side lumbar area. There is no shortness of breath, no chest pain, no leg swelling and she is feeling a bit better on oral iron, but still tired.
Physical examination is unremarkable, with normal vital signs and no palpable abdominal or pelvic masses.
Breast examination shows scar of previous left sided surgery, no new breast lumps and no palpable axillary nodes.
Weight is stable (BMI 26). Bowel test results are back showing both FIT and calprotectin were negative.
You dip the urine again today to see if infection could be the cause of back pain and again it is negative for all but blood 3+.
What do you think is going on? What further workup would you arrange? Put your comments below the line and we will give the answers on 13 August!
Dr Henna Taimoor is a GP in Derby
I would consider an urgent x-ray of the back/ chest to see if there are any secondaries. If that comes back negative, I would consider a DEXA scan and vitamin D if not done already. I would also consider a myeloma screen and FIT test for anaemia.
Age 73, Microscopic haematuria, lumbar pain, fatigue, Asian background – I would suggest urine for cytology, CRP, ESR, sputum for AFB,, X-ray thoracic-lumbar spine and CT abdomen possibility of underlying tuberculosis should be excluded