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Index of Suspicion

Abbreviations: ALT: alanine aminotransferase • AST: aspartate aminotransferase • BUN: blood urea nitrogen • CBC: complete blood count • CNS: central nervous system • CSF: cerebrospinal fluid • CT: computed tomography • ECG: electrocardiography • ED: emergency department • EEG: electroencephalography • ESR: erythrocyte sedimentation rate • GI: gastrointestinal • GU: genitourinary • Hct: hematocrit • Hgb: hemoglobin • MRI: magnetic resonance imaging • WBC: white blood cell

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

	Case 1 Presentation

 
An 11-year-old girl presents to the ED with a 4-day history of right ankle pain. Her pain is worse with movement of the ankle as well as with weight-bearing. Earlier in the week, she had similar symptoms in her left wrist and elbow. She has no history of trauma, fever, or rash. She has had occasional shortness of breath and chest pain over the past week.

Physical examination reveals a well-appearing girl whose axillary temperature is 101.4°F (38.5°C), heart rate is 122 beats/min, respiratory rate is 16 breaths/min, and blood pressure is 97/60 mm Hg. There is swelling around her right ankle as well as tenderness to light touch and pain on flexion and extension of that joint.

Her ankle radiograph is read as normal. Results of laboratory studies include: WBC count, 18.4x10³/mcL (18.4x10⁹/L), with 79% neutrophils, 14% lymphocytes, and 7% monocytes; Hgb, 9.7 g/dL (97 g/L); platelet count, 370x10³/mcL (370x10⁹/L);ESR, 105 mm/hr; and C-reactive protein (CRP), 222 mg/dL. MRI suggests tenosynovitis but cannot exclude osteomyelitis. The joint is aspirated, fluid is sent for culture, and intravenous (IV) antibiotics are started. A development during hospitalization leads to further studies and the diagnosis.

	Case 2 Presentation

 
A previously healthy 16-year-old girl presents to the ED with a right-sided headache that started 6 days ago. Over the past several days, she has experienced right-sided ear pain, decreased hearing on the right, and tingling and weakness of her right foot and hand. Today, she is unable to walk and is slurring her speech. She has no history of fever, trauma, migraines, photophobia, vision loss or changes, dizziness, oral contraceptive use, prolonged travel, drug use, or smoking.

Physical examination reveals an alert and healthy-appearing girl, except for a mild right-sided facial droop, asymmetric smile, tongue . . . [Full Text of this Article]

Heather Liu, MD
Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY

Reina Patel, DO
Benjamin Lee, MD
UTSW Medical School, Children's Medical Center, Dallas, Tex

Jeffrey M. Pernica, MD
David Goldfarb, MD
Megan E. Harrison, MD
Children's Hospital of Eastern Ontario, Ontario, Canada

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