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(Pediatrics in Review. 2005;26:183-187.)
© 2005 American Academy of Pediatrics

Index of Suspicion

The first 300 words of the full text of this article appear below.

	Case 1 Presentation

 
An 8-month-old boy is seen because of a swollen left ankle of several days’ duration. He has had no fever or other signs of illness and has been growing and developing normally.

On physical examination, the infant is alert and cheerful. He has a markedly swollen left ankle and dorsum of the left foot. The ankle is mildly erythematous and warm, with a limited range of motion, and is tender when palpated or moved. The right second toe is edematous, with slight erythema but a normal range of motion. With palpation and passive range of motion, the left ankle is noted to be mildly tender. All other findings are normal.

Laboratory results include: WBC count, 9.1x10³/mcL (9.1x10⁹/L) with 52% neutrophils, 40% lymphocytes, 7% monocytes, and 1% eosinophils; Hgb, 12 g/dL (120 g/L); Hct 36% (0.36); platelet count, 454x10³/mcL (454x10⁹/L); ESR, 69 mm/h; negative findings on urinalysis; negative titers of antistreptolysin O, parvovirus B19 (immunoglobulins G and M), and Lyme antibody; and a negative blood culture. The antinuclear antibody (ANA) titer is positive at 1:640 dilution with a diffuse pattern. A plain radiograph of the left foot shows a widening of the tibiofibular space with soft tissue swelling. A nuclear bone scan demonstrates evidence of left ankle inflammation. Two weeks later, signs of arthritis are evident in both ankles, both knees, and both wrists.

	Case 2 Presentation

 
A 7-year-old girl is brought to the ED after an argument with her older brother. She says that she was slapped several times in the lower lumbar area 5 hours ago. She complains of lower back pain but denies vomiting, abdominal pain, nausea, dysuria, hematuria, neck pain, or headache. She denies being struck in the head and any loss of consciousness.

On physical examination, the . . . [Full Text of this Article]

Laura J. Mirkinson, MD
Children’s National Medical Center, Washington, DC

Paul L. Reed, MD
National Naval Medical Center, Bethesda, Md

Robert Vezzetti, MD
INOVA Fairfax Hospital for Children, Falls Church, Va

MaryEllen Cavalier, MD
James Whitcomb Riley Hospital for Children, Indianapolis, Ind

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