Hot Seat Case #121: 3 year old with new onset weakness
Posted on: November 29, 2018, by : Nancy Gilchrist MD
Nancy Gilchrist, MD Children’s National Medical Center
with Sam Zhao, MD Children’s National Medical Center
HPI: 3 year old female was brought to the ED with new onset weakness. She has had URI symptoms that started 10 days ago, treated initially with hydroxyzine and cough syrup. She was also diagnosed with an AOM 4-5 days ago and is currently on amoxicillin. For the past 4 days the patient has had daily fevers (Tmax 101, approx 1x daily), and she has complained of lower abdominal pain, not associated to urinary symptoms, emesis, or diarrhea. She also has had general malaise, and complained of back pain, and headache. For the past two days, her parents have noticed an abnormal gait. The parents describe her walk as if “she was learning to walk again”. No history of trauma, but they report more frequent falls. The parents mentioned a tick bite several weeks ago.
Of note, the patient was seen in the ED the day prior for abdominal pain. Labs and an abdominal US were normal and the patient was given albuterol for incidental wheezing noted on exam.
PMHx: Vaccines up to date, acute intermittent asthma
PSHx: None
Allergies: NKDA
Family Hx: No significant family medical history
ROS: +abdominal pain, malaise, backache, headache, intermittent left knee pain. No blurry vision, no tingling sensation, no urinary incontinence
PE: Vitals: Temp 37.1, HR 102, RR 34, bp 100/66, O2 sat 100% on RA
General: Alert. appropriate for age. cooperative.
Skin: Warm. no rash.
Head: Normocephalic. atraumatic.
Neck: Supple. no lymphadenopathy.
Eye: Pupils are equal, round and reactive to light. extraocular movements are intact. normal conjunctiva. no discharge.
Ears, nose, mouth and throat: Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm. No murmur. Normal peripheral perfusion.
Respiratory: Tachypneic, Lungs are clear to auscultation. respirations are non-labored.
Gastrointestinal: Soft. Nontender. Non distended.
Genitourinary : Normal rectal tone
Back: Normal range of motion
Musculoskeletal: Normal ROM. normal strength. no tenderness. no swelling. no deformity. Knee’s with no ttp, edema, effusion or erythema bilaterally. FROM of hips bilaterally with passive movement without pain.
Neurological: CN II-XII intact. normal sensory observed. normal coordination observed. developmentally normal. Abnormal gait- pelvis tilted back, legs randomly buckling from weakness bilaterally, 2/4 strength in LLE and 3/4 strength in RLE; normal strength in upper extremities bilaterally. 2+ patellar reflexes present bilaterally.
Psychiatric: Cooperative
Her labs from the day prior were as follows:
CBC 12.66/11.4/33.3/340 with normal diff
BMP 137/3.3/102/19/15/0.37/141, rest of CMP, ESR, CRP and CK wnl
Her repeat CBC was 14/11.7/34.9/389 with a normal diff. Repeat CMP, ESR, CRP, UA, and CK remained wnl. She was given toradol for pain, however, no change was noted on her repeat physical exam.
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Great case! Lots on the differential here – remote tick bite could trigger you to think about erlichiosis or tick paralysis, though the timeline for both is a bit off. Babesiosis fits a little better with the timeline but she doesn’t have a lot of the associated symptoms. Transient synovitis is on the differential but it’s bilateral and she is weak so also less likely. I would expect her to have a higher leukocytosis or elevated ESR/CRP with diskitis or an epidural abscess. Given her true weakness on exam, what I’d be most worried about missing is GBS, though looks like her reflexes are normal. I don’t really have anything specific to ask ortho, so I think I would talk to neurology. If it’s 2 AM, I’d discuss with them if we should keep her in ED until AM (to determine hospitalist vs neuro admit) or admit to hospitalist with consult in AM (my preference). Either way, she isn’t going home.
I agree with Sarah Isbey. I’d also consider AFM (acute flaccid myelitis) and transverse myelitis (less likely given only motor finding) in the differential and would get an MRI with contrast of the spine, which would be easier to obtain urgently after a Neurology consultation in the ER.
Agree with Dewesh..AFM should be included in the DDx. There is no swelling or rash because I’ve seen patients with serum sickness presenting with “weakness” that was actually due to the polyarthralgia…
Agree re above discussion re differential and the need for MRI spine (+ brain). I think it is hard being confident you have exclusively motor findings as opposed to cerebellar in a 3 year old. No indication it will change anything overnight, so I’m not calling anyone to get this done at 3am. Neuro consult is likely to lead to request for LP – I would push back that most of the differentials being appropriately considered above can wait til MRI done under sedation (which is the kinder time to get the LP on this 3 year old).
Agree with all of the comments above. Like Isbey, I usually like to defer non-emergent consults. However, it would be important to find out what Neurology’s recommendations are early on so we can arrange for the appropriate imaging study, which may be more easily obtained from the ED. Other thoughts I have aside from the differential that others have listed would include autoimmune diseases, such as some sort of autoimmune myopathy, multiple sclerosis, myasthenia gravis (although these are much less likely).