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HPI
T.H. is a 2 year old previously
healthy male Fever to 103, NB/NB emesis x 2, and limp x 1 day. Diarrhea x 3 days, approx 2 weeks ago. Complaining of pain with lifting legs up for diaper changes. Taken to PCP the next day with fever of 104F despite motrin and tylenol alternating Q3hr. Admitted to OSH x 4 days, then transferred to PCH.
at birth. No chronic medical conditions. Has had 2 ear infections treated with antibiotics, but none in the past 4 months. Otherwise healthy. PAST SURGICAL HISTORY: No surgeries IMMUNIZATIONS: Up to date including the flu shot. MEDICATIONS: None regularly. Has been taking tylenol and motrin alternating Q3hr with this illness. ALLERGIES: none DIET: normal for age FAMILY HISTORY: PGF with T2DM, otherwise negative for cancer, recurrent infection, arthritis or immunologic diseases. SOCIAL HISTORY: Lives with parents and older sisters ages 9, 7, and 5y. No pets in the home, no recent travel, no exposures to farm or exotic animals.
REVIEW OF SYSTEMS
+fever +complaints of pain in genital region vs hip +vomiting +??Limp +diarrhea 2 weeks ago
- coryza/rhinorrhea
- rash - cough
- swelling/erythema
- no known trauma
PHYSICAL EXAM
T 38.6. HR 140. BP 113/55. RR 34. SaO2 98% on Room Air. WEIGHT - 11.5 Kg, (8th%ile) HEIGHT - 86.5 cm, (10th%ile)
GENERAL: Very irritable with exam during exam, minimally cooperative HEAD: normocephalic, atraumatic. EYES: normal red reflex and pupillary reflexes bilaterally, extraocular movements intact, conjugate gaze, no conjunctival injection. EARS: Normal tympanic membranes, no erythema. NOSE: no discharge or obstruction. OROPHARYNX: moist mucus membranes, no exudate, no pharyngeal erythema. NECK: supple without lymphadenopathy or tenderness to palpation. Normal ROM.
DDx
2 yo M with vomiting, diarrhea, fever, and limp x 4
days
Intra-Articular Conditions Congenital conditions Discoid lateral meniscus Hemarthrosis Hemophilia Trauma Infection Gonorrhea Lyme Disease Septic Arthritis Inflammation Acute rheumatic fever Juvenile Rheumatoid Arthritis Reactive Arthritis SLE Transient Synovitis
Soft-Tissue conditions Infection Cellulitis Pyomyositis or viral myositis Soft tissue abscess Chondromalacia patellae Jumpers knee Osgood-Schlatter disease Sever disease Spinal Conditions Diskitis Spinal Cord Tumors Vertebral Osteomyelitis
Labs:
Pertinent OSH Labs:
CBC: WBC 18.2 (Band 5, Seg 52, Lymph 35), Hgb 11.6, Hct 35.4, Plts
281
BMP: Normal
Blood culture: NG
VRP: Coronavirus OC43+
PCH labs: WBC: 24.0->14.0->13.8->18.2>10.5 CRP: 4.08->2.72->9.18->4.4 ESR: 11->17.0 UA: SG 1.020, pH 6, cloudy, trace protein, neg nitrite, neg LE Urine micro (clean catch): few bacteria Repeat UA: normal
Imaging
OSH: Pelvic Xray normal OSH: Pelvic and Knee US normal Bone Scan: Normal bone scan. No evidence of osteomyelitis.
SPECT: Normal bone scan SPECT of the pelvis and femurs. No evidence of osteomyelitis CT abdomen and pelvis : Normal CT of the abdomen and pelvis. Normal appendix. MRI Pelvis: No sign of joint effusion/synovitis, osteomyelitis, or pyomyositis. MRI L Leg: Very small area of abnormal signal and enhancement in the lateral anterior thigh musculature. No other abnormality. Renal US: Right: Normal. Left: Normal. Abdominal US: No ileocolic intussusception. Small amount of right lower quadrant free fluid.
REACTIVE ARTHRITIS
A form of non-septic
Clinical Manifestations
Several stages involved:
Clinical infection precedes the appearance of arthritis
and/or enthesitis by 1 to 4 weeks Active period of weeks to months Sustained remission or recurrent episodes which may evolve to enthesistis related arthritis, especially in patients that are positive for HLA B27 Acute arthritis and/or enthesitis usually seen (may see tenosynovitis, bursitis, dactylitis) Patients may continue to have fever, weight loss, fatigue and muscle weakness Painless, shallow mucosal ulcers are common Urethritis and cervicitis are rare Conjuctivitis occurs in about two thirds of children at onset
Laboratory Studies
Mild decrease in hemoglobin and leukocytosis
with neutrophilia Elevated inflammatory markers (platelets, immunoglobulins, ESR and CRP) Autoantibodies (RF and ANA) are usually absent but reactive arthritis most frequently occurs in HLA-B27 positive individuals Synovial fluid is sterile Cultures (blood, urine, stool) obtained at the time of infection may be positive
Treatment:
NSAIDs
Meloxicam 2.25mg PO qday x 1-2 months.
inflammatory phase alter the course of the disease Rarely, corticosteroids (oral or intra-articular) may be required
References
Carter JD, Hudson AP. Reactive arthritis: clinical aspects and medical management. Rheum Dis Clin North Am 2009; 35(1):21-44. 2. Rihl M, Klos A, Kohler L, et al. Infection and musculoskeletal conditions: Reactive arthritis. Best Pract Res Clin Rheumatol 2006; 20(6):1119-37.
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