Morning Report

Zoe Raleigh, MD PGY-3

8.19.2015

The Case
ID: 9 year old previously healthy girl with left leg pain x 6 days.
CC: leg pain
HPI:
Leg pain x 6 days starting with left footknee and hip.
4 days prior to admission began limping urgent care and had normal
x-rays. Pain continued to progress.
Day before admission: refusing to bear weight PCP obtained repeat
x-rays, which were normal.
Sent to ED by PCP when she spiked a fever
ROS:
+ Decreased appetite, cough 2 weeks agoresolved without treatment.
- Trauma, rash, vomiting or diarrhea, dysuria, no recent travel.

The Case

ED Course
T 38.7 and tachycardic, BP WNL.
20cc/kg NS, morphine, and ibuprofen prior to admission.
Labs and imaging studies obtained prior to admission to the
floor.
Past Medical Hx:
Born term via C-Section
Obese
Family Hx: Diabetes mellitus, maternal grandmother with breast
cancer. No other cancers, no bone disease, no joint swelling or
lupus.
Social Hx: Lives in Utah with younger siblings. Attends school,
enjoys dancing.

Vitals : T36.6. HR: 104. RR: 22. BP: 115/68 SaO298% on RA.
Weight: 58 kg

GENERAL: Obese, non-toxic appearing girl, laying in bed crying.

HEENT: Normocephalic, atraumatic. PERRL, EOMI, no conjunctival
injection. TMs clear b/l. Nares patent b/l. MMM, no lesions.
NECK: Supple without lymphadenopathy or tenderness to palpation.
CVS: RRR, normal S1/S2, without murmur or gallop. Pulses appropriate.
Capillary <3 seconds.
CHEST/PULM: Symmetric chest rise and no increased WOB. Lungs are
clear to auscultation bilaterally with good air flow throughout.
ABDOMEN: Soft, non-tender, non-distended with active bowel sounds
and no masses or hepatosplenomegaly.
EXTREMITIES: Left leg externally rotated. Swelling of left ankle
and knee joints, both of which are extremely TTP. No
erythema.
NEUROLOGIC: Awake and alert,GCS 15, grossly normal strength and
tone. CN intact.
SKIN: No rash, mottling or unusual birthmarks.

Labs?
Imaging?

Studies
X-rays:
Foot and Hips: normal
Ankle: soft tissue swelling over the lateral malleolus.
Femur: Well-defined 2 cm sclerotic lesion in the proximal
metadiaphysis. No endosteal scalloping, cortical breakthrough, or
periosteal reaction. No significant knee effusion.
Labs:
CMP: WNL
CBC: WBC=21 (0% Bands, 68% Neuts, 19% lymphs, 13%
monos), Hgb=13.5, Plt=330
ESR: 104, CRP: 16.3
Uric acid: 4.7
LDH: 198
Blood culture Pending

Patient Summary
9 year old obese female with fever, joint pain and swelling,
and refusal to bear weight.

Differential Diagnosis
Rheum
JIA
SLE
Reactive arthritis

ONC
Osteosarcoma
Ewing Sarcoma
Rhabdomyosarcoma

ID
Osteomyelitis
Septic joint
Lyme
Transient
Synovitis
MSK
SCFE
Legg-CalvePerthes
Other

Serum Sickness

Hospital Course
HD 1:
Imaging: effusion + synovial enhancement of left hip, knee and ankle.
Knee & Hip tapped in IR.
o Knee: clear fluid and18K WBC.
o Hip: mildly turbid fluid and 53K.

Ortho consulted. Patient underwent hip washout.

Vancomycin following washout.
HD2:
Continued to spike fevers.
Rheum and ID consulted evaluation for GAS and starting Naprosyn.
HD3:
ASO titers elevated and cultures remained NGTDd/c abx
EKG showed prolonged PR interval
Echo: mild mitral regurgitation
Started PCN and discharged home

Post Hospital Course

Seen in Rheum Clinic week after discharge.
o Continues on Naprosyn.
o Follow up 6 months

Seen in Cards Clinic 3 months after discharge.

o No murmur, resolution of PR prolongation.
o Monthly injections until 21st birthday
o Follow up 3 years.

Acute Rheumatic Fever

Definition:
Immune mediated vasculitis following GAS
infection. Clinical diagnosis.
Epidemiology:
Global incidence: ~350K cases per year
US incidence: 0.5-3 cases per 100,000

Pathophysiology

Pathophysiology

Symptoms

Diagnosis
Jones Criteria + evidence of GAS infection
Major

Minor

Polyarthritis
Carditis
Sydenham Chorea
Erythema marginatum
Subcutaneous nodules

Fever
Arthralgia
ESR
CRP
Prolonged PR interval

Treatment
IM injections of penicillin every 3-4 weeks

Rheumatic Heart
Disease

Diagnosis: Cardiac
disease secondary to
acute rheumatic fever.

Leading cause of heart

failure in children

Global prevalence ~1520 million

Rheumatic valvular
disease resolves in 80%
of patients who receive
continuous, long-term
prophylaxis.

References
Marjion E, Mirabel M, Celermajer DS et al.
Rheumatic Heart Disease. Lancet 379: 953-964,
2012.
Khaled Alsaeid & Yosel Uziel. Acute Rheumatic
Fever and Poststreptococcal Reactive Arthritis.
Cassidy and Petty'sTextbook
of Pediatric Rheumatology, Chapter 44, 571585.e4
Bernstein D. Rheumatic Heart Disease. Nelson
Textbook of Pediatrics, Chapter 438, 2269-2271.e1
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