Morning Report

Tyson Jones, MD, PGY2 2/19/14

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.

 PAST MEDICAL HISTORY: Term birth, no complications

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.

PHYSICAL EXAM continued

CARDIOVASCULAR: tachycardic, normal rhythm, normal S1/S2, no murmur, no gallop, normal pulses. LUNGS: clear to auscultation bilaterally, no retractions. ABDOMEN: non-tender, Difficult exam due to upset patient. EXTREMITIES: all extremities warm and well perfused. No cyanosis, or edema including no joint effusion noted. BACK: no abnormalities noted, though difficult to assess GENITOURINARY: normal Male external genitalia. NEUROLOGIC: Fussy with exam, consolable with mom, moves all extremities equally in the bed without gross deficit, patellar tendon reflexes normal. SKIN: no rash MUSCULOSKELTAL: passive ROM intact, though he does exhibit slight guarding of left knee and hip, no erythema surrounding hip, knee, or ankle joints. No joint effusion noted. Normal muscle strength. On fourth exam of the day: Walks with stiff left leg and slightly inturned left foot.

DDx
2 yo M with vomiting, diarrhea, fever, and limp x 4

days

BROAD DIFFERENTIAL FOR CHILD WITH A LIMP:

Bone Conditions: Benign neoplasm Osteoblastoma Osteoid Osteoma Congenital condition Club foot DDH Developmental Condition Legg-Calve-Perthes disease SCFE Infection Osteomyelitis Limb length discrepancy Malignant Neoplasm Ewing Sarcoma Leukemia Osteosarcoma Osteonecrosis Sickle Cell Disease Overuse injury Stress Fracture Trauma Toddlers Fracture Intra-abdominal Conditions Appendicitis Neuroblastoma Psoas-Abscess Neuromuscular conditions Cerebral Palsy Meningitis Muscular Dystrophy Myelomeningocele

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

D dimer 377 Ferritin 141

CK 52 CMP: normal ASO <50 EBV, CMV IgG/IgM: negative Blood cultures: NG Urine cultures: NG

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.

DIAGNOSIS: Reactive Arthritis

REACTIVE ARTHRITIS
A form of non-septic

arthritis developing after an extra-articular infection Arthritogenic bacteria:

GI: Salmonella, Shigella,

Yersinia, Campylobacter GU: Chlamydia, Ureaplasma

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.

No clear evidence that antibiotics during the

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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