The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
An 11-year-old girl with developmental delay presents to the emergency department (ED) with bilateral leg pain. The pain started 4 weeks ago and initially affected only the left leg. At that time, the patient was seen by an orthopedist, who ordered an MRI. MRI revealed hyperintense signaling within the bone marrow of the patella and tibia; this finding suggested edematous change in which cancer could not be ruled out. No other trauma or soft-tissue damage was evident. Physical therapy was recommended.
Over the next 3 weeks, the pain migrated into both legs, and she was unable to ambulate without assistance or the use of crutches. A week before her presentation to the ED, ecchymosis and swelling developed in her legs; the symptoms were worse in the left lower extremity than they were in the right. After her symptoms failed to improve, the orthopedist sent her to the ED to rule out deep venous thrombosis as a cause of her leg swelling.
On further questioning, her mother notes that the patient occasionally has had mild bleeding from her gums but that the amount is not sufficient to raise concern. The mother reports that the patient is a picky eater, and her diet consists almost exclusively of hamburgers and macaroni and cheese. The family usually supplements the patient's diet with a multivitamin; however, she has refused to take it for the past month or so. According to her mother, she has had no fevers, night sweats, exertional fatigue, palpitations, or recent identifiable trauma.
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Cite this: Ecchymosis and Bilateral Leg Pain in an 11-Year-Old Girl With Developmental Delay - Medscape - May 24, 2023.