HPI: A 5-year-old otherwise healthy female presents to the ED from a local urgent care with bilateral ankle swelling and inability to bear weight for the past 3 days. Her mother states that over the past 3 days her ankle swelling and pain have worsened and she is now only able to ambulate by crawling on the ground. Initially, ibuprofen helped resolved the pain; however, today it did not help. Parents also note that she had cough and congestion about 10 days ago. She was diagnosed with strep pharyngitis 7 days prior, and started on amoxicillin. Today at urgent care, a UA in clinic showed 1+ protein.

ROS:

Positive for: bilateral ankle swelling and pain.

Negative for: fevers, nausea, sore throat, nasal congestion, vomiting, diarrhea, rash, hematuria, dysuria, polyuria or blood in the stool.

PMHx: No medical issues. Taking amoxicillin as described above

FHx: No history of autoimmune disorders or renal disease

Social: Lives with both parents. Attends school. No known sick contacts.

Physical Exam:

Vitals:  T 36.9, BP 104/68, HR 99, RR 20, SpO2 100% of RA

General:  Non ambulatory. Patient is alert, interacting, and crying in pain.   

Skin:  No rashes present

Head:  Normocephalic, atraumatic.

Neck:  Supple.  Trachea midline.  No lymphadenopathy. 

Eyes:  Pupils are equal, round and reactive to light.  Extraocular movements are intact.  Normal conjunctiva without discharge or jaundice. 

Ears, Nose, Mouth and Throat:  Oral mucosa moist.  No pharyngeal erythema or exudate. 

Cardiovascular:  Regular rate and rhythm.  No murmur.  Normal peripheral perfusion. Capillary refill < 2 sec

Respiratory:  Lungs are clear to auscultation.  Respirations are non-labored.  Breath sounds are equal.  Symmetrical chest wall expansion. 

MSK:  2+ pedal edema bilaterally from knees to toes. Area with edema is tender to palpation.  Decreased flexion and extension of ankles bilaterally. 

GI:  Soft.  Nontender. Non-distended.  Normal bowel sounds. 

GU:  Normal genitalia for age.

Neurological:  No focal neurological deficit observed.  Reflexes 2+ throughout. Unable to ambulate secondary to pain.

Your initial workup is as follows:

CBC: WBC 11.85, Hemoglobin 11.8, Hematocrit 34.8, Plt 350

CMP: Na 141, K 3.3, Cl 103, CO2 27, BUN 8, SCr- 0.36, Calcium 8.7, Total Protein 7.3, Albumin 3.3, AST 23, ALT 20, T Bili 0.2, Alk Phos 207

UA: pH 6.0, Spec Gravity 1.003, neg LE, neg nitrites, glucose neg, total protein neg, WBC < 1, RBC none

Urine protein/creatinine ratio: 0.3 (norm <0.2)

You give ibuprofen which helps improve her pain; however, your patient is still unable to bear weight.  Your revaluation shows a persistence of bilateral 2+ LE edema without overlying rash or erythema.

You decide to perform additional testing. Your results are as follows:

Respiratory Virus PCR: positive for coronavirus

Complement Levels:  C3 127 (normal), C4 43.2 (mildly elevated), Total compliment: 58 (normal)

Creatine Kinase: 91 (normal)

ASO Titer: 1,200 (elevated)

You discuss the patient with the Nephrology Team. The team has determined that the case does not appear to be a primary renal disease. Your patient is still unable to ambulate but is comfortable in her gurney with Tylenol and ibuprofen. Your exam remains the same. 

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.