Contemporary Pediatrics - September 2008 - (Page 43)

Puzzler One patient, many possible diagnoses George K. Siberry, MD, MPH, Section Editor CHRISTOPHER RAAB, MD, STEPHANIE WALTER, DO, AND KATHRYN E. ITALIA, MD You have just started your hematology/ oncology rotation when you get a call from the general pediatrics service. They are transferring a patient to your service for a leukemia workup. He is an 8-year-old Caucasian boy with a history of leg pain, who now refused to put weight on it. As the senior resident on service, with morning rounds not beginning for another hour, you decide to get started early. DR. RAAB is an attending physician, Division of Diagnostic Referral, and DR. WALTER an attending physician, Division of General Pediatrics, both at Alfred I. DuPont Hospital for Children, Wilmington, Del. DR. ITALIA is a pediatrician at All Star Pediatrics, Lionville, Penn. The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article. SEPTEMBER 2008 CONTEMPORARY PEDIATRICS 43 IMAGE: GETTY/ DIGITAL VISION s you look over his prior records, it appears that his current illness started about six weeks ago, when his mother noticed that he started limping. He then developed discomfort of the left leg severe enough that he could not participate in baseball practice. There wasn’t any swelling or redness, and there was no history of trauma. An initial radiograph of the foot was unremarkable. He was treated with ice, rest, and ibuprofen, but the pain worsened. He was unable to pinpoint a specific joint or area of pain, just that his leg hurt. This prompted a visit to an orthopedist. There it was found that he had full range of motion of the affected leg, except for some restricted internal rotation of the left hip. He had no swelling or effusion, and only mild discomfort of the hip when internally rotated. No palpable tenderness could be elicited. Additional radiographs of both hips and legs were normal, except for some generalized osteopenia. A CBC (complete blood A count), ESR (erythrocyte sedimentation rate), C-reactive protein (CRP), ANA (anti-nuclear antibody), antistreptolysin O (ASO) titer, RF (rheumatoid factor), Lyme antibody, parvovirus antibody, HLA-B27 antigen, and urinalysis were obtained. All were normal except for an elevated ASO titer at 1679 IU/mL (normal <150) and a mild thrombocytosis (444 thous/mcL). Without a throat culture, he was started on amoxicillin for possible post-streptococcal reactive arthritis (PSRA). Four days later, he was again in extreme pain, and refused to walk. His mother took him to the ED to be evaluated. There it was noticed that he had developed petechiae on his upper back, arms, and chest. There was no fever or any other signs of illness. CBC, prothrombin time, partial thromboplastin time, and creatine kinase were all normal. Since it was known that he was being treated for a presumed streptococcal infection, an electrocardiogram was done to evaluate for abnormali-

Table of Contents Feed for the Digital Edition of Contemporary Pediatrics - September 2008

Contemporary Pediatrics - September 2008 Contents Editorial Your Voice Clinical Tip News Updates Eye on Washington Puzzler Dermatology: What’s your Dx? Behavior Cover Story: ECC Epidemic Parent Guides Discipline Techniques: The 12-Month-Old Exercise-induced Bronchospasm: Keeping Our Patients Active Food Safety Parent Guide CPR--Food Safety Malnutrition Links Surgeon General Links Hospice Links Childhood Cancer Links Rx for a Healthy Practice Rx for a Healthy Practice New Products Author Guidelines Journal Club Events Calendar Classifieds Index of Advertisers Postscript

Contemporary Pediatrics - September 2008

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