Aimee Cahill, MD, Children’s National Medical Center

CC:  Pain and swelling of left knee after hitting it on a metal pole 1 week ago. New fever today. Tmax 39 orally.

HPI: Previously healthy fully immunized 10yo AA F presenting from OSH with LLE pain and swelling worsening over past week with new fever today. Pain mostly in left knee that improves some with Motrin. Able to ambulate with toe-touch limp but endorses pain with ROM and weight bearing. Endorses decreased sensation of entire lower leg below the knee.

Patient struck left knee on metal pole 1 week ago with pain the following day that resolved. Pain with swelling returned when patient reinjured left knee a few days later (4 days PTA).. Saw PMD 3 days PTA with normal knee xrays and an MRI scheduled for the following week. However, swelling and pain worsened so was taken to an outside hospital.  XR of left knee, hip, ankle were normal. Patient febrile and tachycardic at OSH so 20cc/kg NSB given.

PMHx: Chronic anemia- iron deficiency? Mom doesn’t remember baseline Hgb. No hospitalizations.
Umbilical Hernia Repair.
No medications. UTD on immunizations. NKDA

FHx: Negative. No Sickle Cell Disease.

ROS:
CONSTITUTIONAL:  +Fever, no chills, +decreased appetite, normal UOP
SKIN: no rash, no hives, no abrasions
EYES: no pain, no redness, no discharge
ENMT: no sore throat, no nasal congestion
RESPIRATORY: no SOB, no cough
CV: no CP, no palpitations, no syncope
GI: no abd pain, no N/V/D
GU: no dysuria, no hematuria
MSK: +lower back pain, +LLE muscle pain  entire leg, +joint pain LLE entire leg
HEME: no known bleeding disorder, no petechial, no purpura,
NEURO: No HA, no seizures, no altered LOC

PE on Arrival:  VS: T 39.4  HR 146   RR 24  BP 122/54  O2 100% RA
GA: WNWD, Alert, appropriate for age, cooperative, Non-toxic
SKIN: warm, dry, +mild erythema and swelling  over Left Knee
HEENT: NCAT, PERRL, EOMI, normal conjunctiva, nares patent, MMM.
NECK: supple, trachea midline
CV: Tachycardic, regular rhythm, no murmur, 2+ radial and DP pulses, CR <2sec
RESP: CTAB w/ equal BS, respirations non-labored
GI: S/NT/ND, normal BS, no HSM
MSK: Limited active ROM of L hip, knee, ankle due to pain. Painful passive ROM  L Compartments full but soft.
NEURO: AAOx3, decreased sensation LLE below knee compared to RLE.

You give motrin and start MIVFs with D5NS. The 2^nd Read of XRs of Left hip, knee, & ankle from OSF show small ankle and knee effusions. You obtain a blood culture, CBC w/ diff and retic, an ESR/CRP, a CMP, and consult orthopedics for arthrocentesis.

 Labs reveal WBC 9.2 (N 81%, Bands 1%)  Hgb 7.0 Hct 19 MCV 72  Retic 0.8%.
ESR 133 CRP 22
CMP normal except albumin 2.3, Tb ili 3.8 Direct Bili 3.5
Knee Synovial Fluid: bloody, RBCs 75K, WBC 1,060 Segs 95%, GS negative

Repeat VS 1.5hrs later: Oral T 37.1  HR 141  RR 24  BP 113/62  O2 100% RA
LLE Pain at and below the knee still 9/10.

You initiate the Sepsis Pathway: 20cc/kg push-pull NSB, IV CTX, IV Vancomycin, another 20cc/kg NSB (patient’s 3^rd overall), continue MIVFs, give Tylenol for pain, and plan to admit to Hospitalists.

Two hours later while awaiting an inpatient bed, Vital Signs: T 36.6  HR 140  RR 20  BP 112/63  O2 100% on room air. LLE with significant circumferential swelling from just above knee down to dorsum of  foot, +warmth, +erythema, exquisite TTP (pt awakens from sleep groaning in pain to light palpation), 2+DP/PT pulses and brisk CR, compartments taut. Left calf circumference 33cm, Right calf 25cm.

Orthopedics re-examines patient after he returns from US and is concerned for developing compartment syndrome but fasciotomy not indicated at this time. LLE Duplex reveals occlusive DVTs in midsuperficial femoral, popliteal, and posterior tibialis. Vital Signs: T 36.7  HR 131  RR 30  BP 110/60  O2 92% on RA. You place patient on 2L BNC and O2 100%.

The EKG shows sinus tachycardia, otherwise normal. Your nurse pulls blood for a D-dimer, PT/PTT INR, Type & Screen, and thrombophilia panel then sends patient to CT.

While waiting for the CT you give patient a 75unit/kg heparin bolus followed by a 20unit/kg/hr heparin gtt. The CT Chest Angio results with no PE but does reveal innumerable septic emboli. You already consulted hematology. You continue the patient on oxygen, IV antibiotics, MIVFs, and the heparin gtt, and admit to the PICU. Four hours after arrival to the PICU orthopedics takes patient to the OR for emergent fasciotomies of his LLE compartments.

Lab Results:

Results of thrombophilia workup:

Anti cardiolipin antibodies IgA<11, IgG<14, IgM<12

Atiii 63% (L), 113

Beta 2 glycoprotein antibodies <9

Ddimer 7.42 (H), 5.38 (H) 

Factor VIII Level 682 (H), 301 on (H)

Factor V Leiden negative on 3/15

Homocysteine 2.6 (L), 3.5 on

Lipoprotein(a) <10

Lupus anticoagulant negative

Protein c function 30 (L) 146 (H) on

Protein s function  17 (L)

PT 15.8,

PTT 30.1

INR 1.25

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