An 8-year-old girl is admitted to the hospital with complaints of right ear pain, right leg pain, left arm pain, and fever after a week of worsening symptoms.
A history of pain
One week prior to admission, the girl had presented to her pediatrician with 7days of right ear pain. She was diagnosed with otitis media and given an antibiotic, of which her mother could not remember the name. She was not having fever at that time.
Five days prior to admission, the patient noticed pain in her right ankle after minor trauma. She was brought to an emergency department (ED), diagnosed with an ankle fracture based on abnormal X-rays, and placed in a splint. The next day, she followed up with an orthopedic surgeon and the ankle was placed in a cast.
Three days prior to admission, the girl began having fever to 104°F along with nausea and vomiting, and she presented to a different ED where she was diagnosed with strep pharyngitis and given azithromycin.
On the day of admission, secondary to continued fever, vomiting of up to 5 times daily, neck pain, left arm pain, and worsening pain in her right ankle, she was again taken to the ED. Labs and X-rays were done. She was given a normal saline bolus, intravenous (IV) morphine, IV ketorolac, IV clindamycin, ondansetron, and then transferred for admission to the children’s hospital.
The patient’s past medical history was significant for allergic rhinitis and an appendectomy at age 2 years. She lives with her mother and grandmother, has no pets, and hasn’t traveled.
On admission, the patient’s vital signs showed an oral temperature of 101.2°F; heart rate of 110 beats/minute; blood pressure of 110/69 mm Hg; and respiratory rate of 20 breaths/minute. Her weight was 45.9 kg (>95%) and her height was 136 cm (50%). She was not in distress but appeared to not feel well. Her right tympanic membrane was erythematous and bulging. She moved her neck easily to the right but had pain with movement to the left. There was no cervical lymphadenopathy.
Her left arm appeared normal but was tender to palpation and movement in all areas of the elbow and forearm. There was no redness or swelling of the elbow or forearm. The right leg was in a cast below the knee. There were 2, 2 mm to 3 mm slightly raised macules that were yellowish in the center with surrounding erythema on the end of her right great toe.
Initial lab results
When the patient presented to the transferring hospital ED, her sodium was 134mEq/L (normal range [NR],135-145 mEq/L) and potassium was 2.9mEq/L (NR, 3.5-5.1 mEq/L). Her white blood cell count (WBC) was 12,600 wbc/mcL (NR, 4.5-13.5 wbc/mcL) with 80% neutrophils (NR, 34%-64%); hemoglobin,9.8 g/dL (normal mean corpuscular volume, normal mean corpuscular hemoglobin concentration,NR,11.5-15.5 g/dL);and platelet count of154,000/mL (NR, 133-450/mL). In the admitting hospital, her albumin was found to be 2.0 g/dL (NR, 3.8-5.4 g/dL); erythrocyte sedimentation rate (ESR) was over 100 mm/hour (NR, 0-10 mm/hour); and C-reactive protein was 171 mg/L (NR, <3 mg/L).
The patient had several objective physical findings including high fever; right otitis media and pain with neck movement; left elbow/arm pain; right foot/leg pain; and pustular rash on the right foot. She also had several laboratory abnormalities including increased neutrophils; a normocytic, normochromic anemia; normal platelets; a low albumin level; and significantly elevated inflammatory markers.