Index of SuspicionCase 1: Lower Extremity Weakness 2 Years After Scoliosis Surgery in a TeenagerCase 2: Fever, Cough, Shortness of Breath, Jaundice, and Hepatomegaly in a TeenagerCase 3: Recurrent Infections in a Teenager

Case 1 Presentation

A 14-year-old girl presents with 10 days of progressive lower extremity weakness together with numbness from her umbilicus to her feet. She denies incontinence but notes difficulty starting her urinary stream as well as constipation. She has no fevers or headaches. There is no recent history of trauma, illness, travel, camping, or insect bites. Two years before presentation, she underwent a posterior spinal fusion for idiopathic scoliosis without complications. She has done well, and her progress is monitored regularly by her orthopedic surgeon, who notes that she has complained intermittently of mild back discomfort but has had no back pain in the past few weeks. There is no family history of tumors, neurologic disorders, or autoimmune diseases.

On physical examination, the girl is afebrile and has stable vital signs. She is alert and in no distress. Her skin is free of rashes and acne. Her cranial nerves are intact, and her neck is supple. There is no spine tenderness or erythema on her back. Her upper extremity strength is normal. Lower extremity strength is decreased to 2–3/5 on the left and 4/5 on the right, with normal tone, bilateral 4+ hyperreflexia, and 3 beats of clonus. She has normal rectal tone and decreased sensation to touch, pinprick, and vibration in her legs. Proprioception is difficult to elicit. She walks with support and without ataxia.

Laboratory evaluation shows white blood cell (WBC) count of 10.7 × 10³/μL and hemoglobin concentration of 10.2 g/dL. Her cerebrospinal fluid WBC count is 13/μL, her glucose level is 63 mg/dL, and the protein concentration is 225 mg/dL. Her erythrocyte sedimentation rate is 27 mm/h, and her C-reactive protein level is 4.6 mg/L. An imaging study reveals the diagnosis.

Case 2 Presentation

A 13-year-old boy presents with fever, cough, breathing difficulty, and reduced oral intake for 6 …