Pediatric Rheumatology Online
Journal
Vol. 2, No. 1 (103-104 ) 2004
FELLOW'S CHALLENGE CASE
JANUARY-FEBRUARY 2004
An 8 year old girl is brought to you
with a two month history of leg pains. At onset, the pains began in her arms
and legs and occurred once to twice a week. The pains were mild and lasted only
one hour or so. They were believed to be growing pains and resolved after four
weeks. The child was well for two weeks. Then the parents noted that the child
was limping, favoring the right leg. The arm and leg pain returned and was more
severe and more frequent. A fleeting maculopapular rash was present for two
days.
The child’s pediatrician referred
her to an orthopedist. On exam the physician noted mild pain and limitation
with internal rotation of the right hip and diagnosed toxic synovitis. She
prescribed ibuprofen and reassured the family that this problem should resolve
soon. Unfortunately, the pains worsened and now woke the child up at night. She
began having fevers to 38.5 degrees centigrade. The pediatrician reevaluated
the child and found a mildly swollen left knee, tender left shin, and the
mildly painful, limited right hip. He ordered lab tests. The lab results were:
1) CBC-hemoglobin 10.2 g/dl, WBC 4,300 cells/mm3, differential 45% PMN’s, 42%
lymphocytes, 5% eosinophils, 3% monocytes, 2% basophils; platelet count 500,000
cells/mm3; 2) ESR 52 mm/hour; C-reactive protein 1.3 (normal <0.2); ANA + at
titer 1:160. The pediatrician then referred the child to your pediatric
rheumatology clinic.
At the child’s appointment at your
clinic one week later, she cannot walk and is brought to you in a wheelchair.
Your exam reveals mild limitation and pain of both hips. Lab tests reveal a WBC
of 4000 cells/mm3 (40% PMN’s, 55% lymphocytes, 4% monocytes, 1% eosinophils), a
hemoglobin of 9.4 g/dl, a platelet count of 310,000 cells/mm3, an ESR of 65
mm/hour, an ANA of 1:160, and a negative rheumatoid factor. You obtain radiographs (Figure 1).
Your
most likely diagnosis is:
1) osteomyelitis (a Brodie’s abscess)
2) juvenile rheumatoid (idiopathic) arthritis, systemic
onset
3) acute lymphoblastic leukemia
4) psoriatic arthritis
5) neuroblastoma
6) CRMO (chronic recurrent multicentric osteomyelitis)
Please
e-mail your answer to Linda Wagner-Weiner.
The first correct answer will receive the CD-ROM of Pediatric Slide Collection
of the
