LAUSR

1. John Mangan, MD* 2. Darshan Shah, MD* 3. April Troy, MD, MPH* 4. Dennis Dawgert, MD* 1. *The Commonwealth Medical College, Scranton, PA An 18-year-old boy presents with right-sided jaw pain, migratory body pains, decreased appetite, pain on deep inspiration, severe odynophagia, and dark urine. He had no history of sick contacts or international travel. He was evaluated a week earlier for a sore throat, moderate dysphagia, fever, and decreased energy. On physical examination at that time he was found to have an erythematous posterior pharynx, moderately enlarged tonsils, and cervical lymphadenopathy. His streptococcal antigen and Monospot test results were negative. He was prescribed corticosteroids and naproxen for pain and severe tonsillar enlargement. Physical examination shows an erythematous posterior pharynx without exudates, severely enlarged tonsils, pleuritic chest pain on deep inspiration, and right mid-thoracic paraspinal tenderness. Vitals on presentation are a temperature of 102.4°F (39.1°C) and a heart rate of 90 beats/min. The remaining physical examination results are normal. He is hospitalized for further evaluation and treatment with ceftriaxone for concern for peritonsillar abscess. Laboratory evaluation shows a white blood cell count of 24×103/μL with 60% neutrophils and 25% bands, a platelet count of 115×103/μL (115×109/L), a blood urea nitrogen level of 30 mg/dL (10.7 mmol/L), and a creatinine concentration of 1.1 mg/dL (97.2 μmol/L). Urinalysis shows trace ketones, 5 to 9 red blood cells per high-power field, a urobilinogen level of 8 mg/dL, 2+ bilirubin, and 1+ protein. A chest computed tomographic (CT) scan is performed because of pleuritic chest pain and shows interstitial pneumonia with possible septic …