A 5-Year-Old With Leg Pain

A 5-Year-Old With Leg Pain
Adapted from Comp Orthop 12(1):13-16, 1997

Abstract: A 5-year-old boy with leg pain and possible diabetes mellitus is discussed. The diagnosis was confounded by previous trauma and systemic illness. Swelling of the leg may have been due to trauma. Autopsy reveals streptococcal fasciitis.

Introduction

A 5-year-old African-American boy presented to his private pediatrician's office with a 1-day history of pain and difficulty bearing weight on his left leg. He had fallen down in school the day prior to admission, but there was no additional history of trauma. He was noted to be febrile and somewhat "groggy" in the doctor's office. During the past 2 to 3 months, his parents noted an increase in his appetite along with enuresis on 2 occasions. For this reason, a urine dip-stick analysis, which was positive for glucose and negative for ketones, was done in the office. He was then referred as a direct admission for evaluation of diabetes mellitus and suspected leg trauma.

Four days prior to admission, he had been seen in the emergency department with low-grade fever, vomiting, and loose stools. At this presentation, he had a temperature of 101.8deg.F but was not thought to be toxic. The physical examination was unremarkable, and he was sent home with a diagnosis of gastroenteritis. No medication except acetaminophen was prescribed.

On admission, the patient had a temperature of 104.5deg.F; a heart rate of 126 beats/minute (normal mean, 100); respiratory rate of 36 breaths/minute (normal, 22+/-2); and a blood pressure of 109/53mm Hg (mean, 95/55). His weight was 21.3kg (eightieth percentile). He looked sleepy but was responsive and cooperative during the exam, although he complained intermittently of pain in his left leg. Positive findings were limited to examination of the left lower extremity, where there was mild swelling and tenderness of the calf up to the knee without erythema or other evidence of cellulitis. A dorsalis pedis pulse was palpated in the left foot but was thought to be decreased. Measured circumference at the mid-calf of the left leg was 3cm greater than a similar measurement of the right leg. There was full range of motion of both the ankle and the knee. During his work-up in the emergency department, pain in the left leg increased to the point that it was very difficult for him to assume a comfortable position.

Admission laboratory assessment included a leukocyte count of 5000/mm³ (28% segmented forms, 62% band forms, 8% lymphocytes, 1% monocytes, and 1% metamyelocytes). Hemoglobin was 11.5g/dL and platelets were 238,000/mm³. Examination of a peripheral smear revealed toxic granulations, vacuolated granulocytes, and Döhle bodies, each graded 2+/4. Glucose was 130mg/dL, electrolytes were normal, and creatinine was 0.8mg/dL. A chest radiograph was normal, and plain films of the left lower extremity showed mild diffuse soft-tissue swelling but no fracture. Blood, urine, and stool cultures were obtained, and intravenous cefuroxime was begun approximately 4 hours after admission.

What is the Differential Diagnosis?

References

Orthopedics Treatment Updates from MedScape

Benjamin Estrada, MD,*^†Dennis L. Stevens, MD, PhD,^‡§ Randall D. Craver, MD,* Russell W. Steele, MD* Comp Orthop 12(1):13-16, 1997.

Go to Cinical Microbiology Page
Go to IUSM-TH Microbiology Homepage.
Go to Indiana University School of Medicine Homepage.

Introduction

What is the Differential Diagnosis?

This document was created by Mary T. Johnson, Ph.D. Last modified November 27, 2007