Case 1: Erythema and Inability to Bear Weight in a 12-year-old Girl

Editor’s Note

This month, many people use Valentine’s Day as an opportunity to celebrate loving relationships. As seen in some of this month’s Index of Suspicion cases, though, sometimes health problems result from imperfect relationships. As pediatricians, we have the privilege of working for the best possible outcomes for children and their families.

Philip R. Fischer, MD

Associate Editor, Index of Suspicion

Presentation

A 12-year-old previously healthy girl is admitted to the hospital from an orthopedic surgeon’s office due to concern for osteomyelitis 2 weeks after an injury while playing soccer. She began having foot pain and erythema after her foot was stepped on during a soccer match. A radiograph of the foot taken on the day of injury was negative for fracture. During the 10-day period after the injury, she describes decreased ability to bear weight and progression of erythema and tenderness over her dorsomedial right foot. She and her mother also report consistent fevers at home, with the highest recorded at 103°F (39.4°C).

A sports medicine physician saw her on the tenth day after her injury. The complete blood cell count and C-reactive protein level at his office were normal. She was started on clindamycin for a presumptive diagnosis of cellulitis, and she was referred to orthopedics for further evaluation. She was seen by orthopedics 2 days later and was sent for admission to the hospital due to worsening erythema and inability to bear weight. She had taken 4 doses of clindamycin by the time of admission with no apparent improvement in symptoms. Her mother has pictures showing the progression of erythema along the foot …