Fever and Limp in a 3-Year-Old Girl

Setshedi Makwinja, MD; Ben Numpang, MD; Benjamin R. Aubey, MD, MPH

Disclosures

October 28, 2015

Physical Examination and Workup

Upon physical examination, the patient's vital signs are stable, with a blood pressure of 103/66 mm Hg, pulse rate of 115 beats/min, respiratory rate of 24 breaths/min, and an oxygen saturation of 100% while breathing room air. Her temperature is 97.5°F (36.4°C). The patient initially refuses to bear weight on the right leg and is unwilling to walk. She is tearful and uncooperative as a result of the pain.

Figure 1.

Figure 2.

The respiratory and cardiac portions of the physical examination are normal. The abdominal examination is also normal, with no palpable masses or tenderness to deep palpation. There is localized exquisite tenderness over the L1-2 region of the back, with slight induration noted in the overlying tissue. The lower extremities are well-perfused, with intact peripheral pulses; no external evidence of trauma is found. There is no limitation in the range of motion at the hip and knee joints bilaterally, with unremarkable obturator and psoas signs. The neurologic examination findings are normal. No lymphadenopathy is detected.

Figure 3.

Figure 4.

The initial laboratory investigations reveal an elevated white blood cell count of 20.5 × 103/μL (20.5 × 109/L; neutrophils, 66.5% [0.66]; lymphocytes, 21% [0.21]; monocytes, 11.3% [0.11]), an elevated erythrocyte sedimentation rate of 87 mm/h, a C-reactive protein (CRP) level of 49.5 mg/L, a creatine kinase of 69 U/L, and a lactate dehydrogenase of 247 U/L. The urinalysis is normal, with no evidence of infection or hematuria. Plain x-rays of the lumbar spine are obtained (see Figures 1 and 2) and are essentially unremarkable. Due to a high suspicion for serious pathology based on the clinical presentation and the results of the laboratory investigations, urgent MRI scans of the spine are also obtained (see Figures 3 and 4).

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