Visual Diagnosis: Petechiae, Gingival Hyperplasia, Metaphyseal Lucencies, and Refusal to Ambulate in a 5-year-old Boy

Nithin S. Ravi; Niyomi Gandhi; Stacey Noel; Carolyn Commissaris; Austin Michalski; Yiling Katharine Chang

doi:10.1542/pir.2018-0080

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Nithin S. Ravi, MD, MPH*
Niyomi Gandhi, MD†
Stacey Noel, MD‡
Carolyn Commissaris, MD‡
Austin Michalski, RD§
Yiling Katharine Chang, MD†

^*University of Michigan Medical School, Ann Arbor, MI;
^†Department of Pediatrics,
^‡Department of Pediatric Emergency Medicine, and
^§Patient Food and Nutrition Services, CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI

AUTHOR DISCLOSURE
Drs Ravi, Gandhi, Noel, Commissaris, and Chang and Mr Michalski have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Dr Gandhi's current affiliation is General Pediatrician, Uphams Corner Health Center, Dorchester, MA. Dr Ravi’s current affiliation is the University of Pittsburgh, Pittsburgh, PA.

Presentation

A developmentally normal 5-year-old boy presents to the emergency department with epistaxis, arthralgias, refusal to ambulate, and gingival hyperplasia. Six weeks before presentation, the patient developed bilateral lower-extremity arthralgias. One week later, he fell and subsequently refused to ambulate. At the initial evaluation by his pediatrician, he had normal lower-extremity radiographs with appropriate growth and development for age, so no further recommendations were provided to the parents.

During the following 2 weeks, the pain in his lower extremities progressed to his lower back, wrists, and hands. The patient presented to an outside hospital, where plain radiographs revealed a stress fracture of the left tibial plateau that was treated with casting. Two days before presentation, the cast was removed, and a petechial rash in the distribution of the cast was noted, with associated joint swelling. A rheumatology appointment was scheduled.

On the day before his scheduled rheumatology appointment the patient presents to the emergency department. The parents state a chief complaint of “vomiting bright red blood.” With additional history, this is determined to be more consistent with epistaxis than with hematemesis. Vital signs reveal mild tachycardia of 132 beats/min but are otherwise normal. Weight is normal for age at 38.4 …