Hot Seat #157: 10 day old with elbow swelling

Posted on: September 19, 2020, by :

CC: 10 day old girl with elbow swelling

HPI: 10 day old ex FT girl presenting with left elbow swelling and decreased movement of left arm. Parents report that in the middle of the night, they noticed she was not moving her left arm the same way she was her right. Waking every 1-3 hours to feed, wet and dirty diapers qfeed. 3 days ago, temp was 99 on temporal thermometer, 100.1 rectally, checked 3 minutes later and 99.3 without acetaminophen. No known trauma, however, mother notes that she fell asleep on her side while nursing 2 days ago.

PMH: Born 40 weeks NSVD. Labor 26 hours. No birth traumas. Discharged home with mother. Received vitamin K.

Meds: vitamin D

FHx: No family history of epilepsy, seizures, bleeding/clotting disorders, recurrent infections.

SHx: Lives with mother and father. No sick contacts. No other caretakers.

ROS:

Gen: No fevers. Diapers : normal amount Oral intake: breastfeeding well

Skin: No rash, no bruising

Eye: No redness, no discharge

ENT: No nasal congestion

Respiratory: No increased work of breathing, no stridor, no apnea

CV: no nursing cyanosis, no nursing diaphoresis

GI: no vomiting, no diarrhea

GU: no hematuria

Neuro: no seizures, no altered level of consciousness

Physical Exam:

T 37.7 HR 150 RR 32 BP 81/56 SpO2 97%

Gen: Alert, appropriate for age

Skin: warm, dry, pink, no rash.

Head: AFOF, NC/AT

Eye: PERRLA, normal conjunctiva, moving eyes spontaneously

ENT: Oral mucosa moist

CV: RRR, no murmurs, WWP, distal pulses 2+

Respiratory: lungs clear bilaterally, no increased WOB

GI: Soft, NT/ND, normoactive bowel sounds

MSK: moving legs bilaterally with 5/5 strength, right UE with normal range of motion, normal strength. Reduced movement of left arm, holds left arm extended posture, able to abduct arm at shoulder spontaneously, does not spontaneously move left hand/wrist/elbow. No overlying skin changes including erythema or bruising.

Neurologic: opens eyes to mother. Asymmetric Moro reflex: does not flex left arm. Reduced grasp present in left hand, reduced tone in left arm, fussing with flexion/extension at left elbow joint. Normal axial tone. Normal tone in right arm, bilaterally lower extremities.

Labs:

CBC WBC 13 H/H14.2/40.7 Plt 745

ESR 55, CRP 3.61

Chem: Na 138, 4.5, Cl 101, CO2 26, BUN 10, Cr 0.21, Glucose 87

Left UE x-ray is normal

HUS showed small R choroidal cyst, otherwise unremarkable.

US: complex left elbow joint effusion (likely hemarthrosis) without evidence of radio-capitellar subluxation-dislocation. Normal shoulder joint. No subperiosteal fluid.

Orthopedics is consulted given joint effusion and requests repeating the ultrasound while they are present to tap the joint.

Orthopedics taps the elbow effusion under ultrasound guidance, obtains 4cc of cloudy, bloody fluid.

Joint aspirate:

WBC 260,000 with 92% neutrophils

LP Obtained: CSF: RBC 3000 WBC 10 glucose 63, protein 54

ID was consulted, recommended who recommended starting patient on Oxacillin/Gentamicin

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Mary Beth Howard
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2 thoughts on “Hot Seat #157: 10 day old with elbow swelling


  1. Was there a prenatal GBS screen? GC and chlamydia? Treatment of either before delivery?
    This sounds like GBS arthritis to me, but it is a bit early at 10d. It is a late onset form of GBS.
    GNRs can do this. Gonorrhea too, although I have never seen it.


  2. I think it’s one thing to argue against tapping for infant UTIs (well-appearing infants over 30 days old given the low prevalence of bacterial meningitis for infants 20-90 days old with UTI), but this neonate is 10 days old, has bacterial arthritis (exam findings, synovial fluid WBC count over 50,000 with >90% PMNs), has borderline temperatures, and an abnormal exam noticed by parents and staff. Needs the full septic workup and antibiotics while awaiting all your culture results (blood, urine, CSF, synovial fluid), and likely ID involvement given the atypical presentation. With a normal head ultrasound and a presentation that is consistent with infectious etiology, I think we can hold off on brain MRI, unless there were additional neurologic exam changes and or further work-up that argued against an infectious source.

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