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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

 
A 15-year-old boy presents with pain, swelling, and limited movement of his right elbow for 4 days. He denies other joint involvement, trauma, headache, diarrhea, visual disturbances, or dysuria but has experienced night sweats. He had streptococcal pharyngitis and a mononucleosis-like illness 3 months ago. He has no pets, and his only travel occurred more than 1 year ago when he visited Mexico. He is not sexually active. Naproxen helped initially, but his symptoms have worsened.

Physical examination reveals a nontoxic adolescent boy whose temperature is 37.4°C, heart rate is 74 beats/min, and blood pressure is 127/69 mm Hg. There is no erythema around his right elbow, but it is swollen, tender, and warm, and it feels boggy. His elbow's range of motion is limited from 90 to 120 degrees. The rest of his examination findings are normal.

His WBC is 5.9x10³/mcL (5.9x10⁹/L), with a normal differential count, Hgb is 13.9 g/dL (139 g/L), Hct is 41.7% (0.42), and platelet count is 245x10³/mcL (245x10⁹/L). His ESR is 50 mm/hr and C-reactive protein measures 11.3 mg/dL. Elbow aspiration reveals cloudy fluid, with 9,761 red blood cells and 3,967 WBCs but no crystals. Gram stain shows moderate neutrophils but no organisms. Aspirate is sent for bacterial and fungal cultures.

The patient is discharged on naproxen and instructed to obtain a follow-up appointment in a few days. A call from the laboratory 4 days later helps to establish the diagnosis.

	Case 2 Presentation

 
A 7-year-old boy presents to a hospital in Florida with 3 weeks of headache refractory to acetaminophen and 1 day of altered mental status, diplopia, and photophobia.

On physical examination, the well-developed, prepubertal boy has a weight of 37.7 kg (>97th percentile), temperature of 36.8°C, heart rate of 101 beats/min, and . . . [Full Text of this Article]

Daniel H. Reirden, MD
The University of Colorado Denver School of Medicine, The Children's Hospital, Aurora, Colo

Alexandra N. Menchise, MD
Brian Knox, MD
Rani Gereige, MD, MPH
Department of Pediatrics, University of South Florida, Tampa, Fla

Tamara Howard, MD
Erica L. Thomas, MD
Baylor College of Medicine, Houston, Tex

Rosina Connelly, MD, MPH
University of South Alabama, Mobile, Ala

Sarah Tyler, MD
Katie McPeak, MD
Children's Hospital of Pittsburgh, Pittsburgh, Pa

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