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    Child’s ear pain progresses to leg pain, arm pain, and fever

     

    The anemia, hypoalbuminemia, and elevated inflammatory markers suggested the patient had a significant inflammatory process. The differential diagnosis of fever and extremity pain is fairly extensive (Table). Hematogenous osteomyelitis, leukemia, and endocarditis with septic emboli to the extremities were strongly considered in this order.

    Because of the patient’s primary complaint of limb pain and fever, the physicians considered osteomyelitis and consulted Orthopedic Surgery. They recommended to rule out leukemia due to fever and the involvement of more than one limb. In a child, leukemia can cause multifocal bone pain because of decreased production of all blood cell lines and leukemic infiltration. Such a child also can have intermittent fever that may result from production of cytokines or infection due to leukopenia. When leukemia is suspected, a peripheral smear should be ordered and indirect tests of tumor lysis such as lactate dehydrogenase and uric acid should be done. A bone marrow biopsy is required for definitive diagnosis, so Hematology was consulted. Given that the patient had a normal complete blood cell count except for mild anemia and a peripheral blood smear without blasts, Hematology believed leukemia was unlikely.

    Next, the patient’s physicians returned to their initial thought of hematogenous osteomyelitis. She had a high fever and pain in her right lower extremity, which is commonly seen with osteoarticular infections. More than 80% of osteoarticular infections occur in lower extremities and 20% have a history of injury or fall in the recent past.1In 1999, Kocher and colleagues developed a clinical prediction scale that included the following 4 criteria: fever, refusal to bear weight, white blood cell count above12,000wbc/mcL, and an ESR over 40 mm/hour. The diagnostic sensitivity for acute osteomyelitis was 93% for 3 criteria and 99% for 4 criteria.2

    Recommended: Acute otitis media warrants 10 days of antibiotics

    Plain films can be obtained with extremity pain and fever but the sensitivity of radiography for detecting osteomyelitis is only 50%.3 This patient had multiple X-rays of her right lower extremity and left upper extremity at the transferring hospital ED that were read as normal. When the site of acute infection can be determined, magnetic resonance imaging (MRI) is the best imaging method because of the excellent images of soft tissues, bones, and joints.1

    Because her right foot/ankle was the site of the most pain, and because she had fever, the patient underwent a right ankle MRI with and without contrast. It showed fluid collections in the anterior ankle compartment and flexor digitorum muscle, which were concerning for abscesses due to hematogenous spread (Figure1). The patient was taken to the operating room where the 2 abscesses were drained. The wound culture grew many group A beta-hemolytic strep. To assist with antibiotic choice and duration of therapy, Infectious Diseases was consulted. Her antibiotics were switched from IV cefepime and vancomycin to ampicillin/sulbactam.

    Because of the abscesses and embolic-appearing lesions on the patient’s right foot, the physicians considered endocarditis. Infected vegetations on heart valves are known to embolize to other parts of the body. With right-sided endocarditis, a patient can develop septic pulmonary emboli. When vegetations on are the left side, septic emboli can travel to the brain or anywhere else in the body such as the extremities. Because of the concern for septic emboli, the patient underwent a transthoracic echo that was negative for vegetations but that showed a tiny patent foramen ovale with a left-to-right shunt. Septic emboli can pass through this patent foramen ovale, but the question became from where did they originate?

    NEXT: Further investigations

    Holly D Smith, MD
    Dr Smith is an assistant professor in the Department of Pediatrics, McGovern Medical School, Houston, Texas.
    Peter T Scully, MD
    Dr Scully is a second-year pediatric critical care fellow in the Department of Pediatrics, McGovern Medical School, Houston.

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