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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 and Yiling Katharine Chang
Pediatrics in Review December 2020, 41 (12) e46-e49; DOI: https://doi.org/10.1542/pir.2018-0080
Nithin S. Ravi
*University of Michigan Medical School, Ann Arbor, MI;
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Niyomi Gandhi
†Department of Pediatrics,
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Stacey Noel
‡Department of Pediatric Emergency Medicine, and
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Carolyn Commissaris
‡Department of Pediatric Emergency Medicine, and
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Austin Michalski
§Patient Food and Nutrition Services, CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
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Yiling Katharine Chang
†Department of Pediatrics,
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  1. Nithin S. Ravi, MD, MPH*
  2. Niyomi Gandhi, MD†
  3. Stacey Noel, MD‡
  4. Carolyn Commissaris, MD‡
  5. Austin Michalski, RD§
  6. Yiling Katharine Chang, MD†
  1. *University of Michigan Medical School, Ann Arbor, MI;
  2. †Department of Pediatrics,
  3. ‡Department of Pediatric Emergency Medicine, and
  4. §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 …

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Pediatrics in Review: 41 (12)
Pediatrics in Review
Vol. 41, Issue 12
1 Dec 2020
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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
Pediatrics in Review Dec 2020, 41 (12) e46-e49; DOI: 10.1542/pir.2018-0080

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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
Pediatrics in Review Dec 2020, 41 (12) e46-e49; DOI: 10.1542/pir.2018-0080
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