Severe Back Pain and Fever in a 9-year-old Boy

A 9-year-old, previously healthy and fully immunized boy is transferred to our children’s hospital from a community hospital with fever, tachycardia, and a 2-day history of severe pain of his upper back. The severity of his pain prompted 2 other health-care visits in the preceding days to a clinic and a community hospital emergency department. He was discharged both times with a diagnosis of musculoskeletal pain despite no compatible history. He presented to the local emergency department for a second time due to increasing severity of pain localized between his scapulae and new onset of tactile fever. Review of systems is negative for headache, shortness of breath, symptoms of an upper respiratory tract infection, or weight loss, although it is positive for altered mental status (obtundation), photophobia, and back pain with movement. Travel history is notable for immigration from India 2 years earlier, with recent travel back to visit family...