This case involves a male patient in his twenties who presented to the ER with pain in his right hip that had gotten progressively worse over the course of a week. Upon admission, he was found to have a severely elevated temperature, and had reportedly been suffering from severe chills the day prior to presenting to the hospital. He had a markedly elevated CPK and elevated D-dimer, and was complaining of extreme pain in his right hip. Despite being admitted to the hospital, doctors failed to recognize that he was suffering from a necrotizing soft tissue infection in his hip. The patient died after two days in the hospital.
Question(s) For Expert Witness
1. What is the differential diagnosis for patients presenting with pyrexia and muscle pain?
2. What investigations should be ordered to rule out infection with patients with elevated CPK and D-dimer?
Expert Witness Response E-052916
The differential diagnosis for pyrexia and muscle pain is broad and includes infectious, inflammatory and toxic disorders. Specific infectious disorders include any acute viral syndrome, infectious myositis, and necrotizing fasciitis. Inflammatory disorders include a number of rheumatologic diseases, rhabdomyolysis, and toxic disorders include neuroleptic malignant syndrome and serotonin syndrome. An elevated CPK is often seen in necrotizing fasciitis. Other common findings are abnormal white blood cell count (high or low) and lactic acidosis. The key to diagnosis is a high index of suspicion in a patient presenting with muscle pain who just generally looks very unwell, followed by a surgical biopsy or exploration. CT and MRI may be helpful but cannot rule out the disease on their own. I have extensive teaching, research, and quality and safety experience.
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