Pediatrics in Review
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(Pediatrics in Review. 2001;22:95-103. doi:10.1542/10.1542/pir.22-3-95)
© 2001 American Academy of Pediatrics

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Index of Suspicion




   Case 1 Presentation
 
A 16-year-old boy limps into the clinic complaining of severe pain in his right knee, which has been swollen and painful for 5 days. He cannot bear much weight or straighten the leg. One week ago, he fell onto his right wrist and right knee. Two days later, his wrist was improving, but he had pain in his left ankle. Radiographs of the ankle revealed no fracture. Yesterday his right shoulder started to hurt. All joints are better now except his right knee.

He has had fevers since yesterday, chills today, nausea and a decreased appetite for 1 week, but no vomiting or diarrhea. He had a mild sore throat 2 weeks ago. A red rash started yesterday on his right knee and appeared briefly on his neck. The boy lives with his mother; they have hamsters, guinea pigs, a cat, a dog, and a pet rat, purchased just 2 days ago.

The patient had unprotected heterosexual sex 2 months ago. He denies dysuria, frequency, penile discharge, or a history of sexually transmitted disease. His sister has "small joint" rheumatoid arthritis, his mother has Marfan syndrome, and a grandmother has had rheumatic fever.

On physical examination, the boy appears uncomfortable. His temperature is 38.9°C (102.0°F) orally, pulse is 90 beats/min, respirations are 20 breaths/min, and blood pressure is 115/58 mm Hg. Remarkable findings include mild pain on full abduction of his right shoulder; a slightly swollen but nontender left ankle; and a markedly swollen right knee that has limited flexion, is exquisitely tender, and has an area of salmon-colored macular erythema over the patella that fades within the hour.

Laboratory results include white blood cell count, 10.5 109/L (10,500/cu mm), with 8% band forms, 74% segmented neutrophils, 9% lymphocytes, and 9% monocytes; hemoglobin, 144 g/L (14.4 g/dL); platelet count, . . . [Full Text of this Article]


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Clin. Microbiol. Rev., January 1, 2007; 20(1): 13 - 22.
[Abstract] [Full Text] [PDF]


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