PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting (virtually) at the National Conference and Exhibition I will be sharing three cases online in advance of the conference. This is the third of the three cases.
This case was submitted by…
A 9-year-old, previously healthy child presented with fever, chills, headache, joint pain, and rash. Symptoms started with the fever, then on day 3 he developed abdominal pain and chills. At a referring facility he had a CT of the abdomen consistent with mesenteric adenitis and an unremarkable CBC and CMP. On day 6 the patient developed rash and joint pain. On day 12, had had difficulty walking due to worsening joint pain – as well as sore throat and headache. Given the ongoing and worsening complaints he presented to the Pediatric Emergency Department.
Physical Examination
Vital Signs 144/95, HR 96, T 37.5, RR 22
Constitutional tired appearing, non-toxic
Cardiovascular Normal heart sounds, regular rate and rhythm
Pulmonary clear to auscultation bilaterally
Abdominal soft, non-distended, non-tender, no hepatosplenomegaly
Musculoskeletal pain with ROM of b/l shoulder, knees, ankles without swelling or warmth
Skin blanching nonpalpable red/purple macules on bilateral feet
Additional labs revealed the following:
CBC with differential
| WBC | 13.3 x 109/L |
| Hemoglobin | 12.2 q/L |
| Hematocrit | 36% |
| Neutrophil | 74.5 x 109/L |
| Lymphocytes | 12.0 x 109/L |
| Monocytes | 11.3 x 109/L |
| Eosinophils | 1.6 x 109/L |
| Basophils | 0.6 x 109/L |
Complete metabolic panel
| Na | 136 mEq/L |
| K | 4.0 mEq/L |
| Cl | 100 mol/L |
| BUN | 7 mg/dL |
| Cr | 0.4 mg/dL |
| Ca | 10.1 mg/dL |
| AST | 149 IU/L |
| ALT | 196 IU/L |
Others
| ESR | 57 mm/hr |
| CRP | 8.2 mg/L |
| Procalcitonin | 0.1 ug/L |
| RVP | Negative |
| Mono Spot | Negative |
| Rapid Strep | Negative |
