Hot Seat #142 Denouement: 5yoF with inability to walk

Posted on: December 20, 2019, by :

The case: 5yoF presenting with acute bilateral ankle arthritis and associated painful lower extremity edema in the setting of treatment for Group A Strep

Here’s how you answered:

Discussion: The discussion focused widely on the differential and whether this was an uncommon presentation of a common entity, or a common presentation of an uncommon diagnosis. Initial thoughts were acute serum-like sickness vs possible acute rheumatic fever, though different clinical aspects argued against both. Another person brought up HSP given lower extremity findings and an initial UA with proteinuria. In terms of management, as shown above, most agreed with need for further observation and symptomatic management.

Denouement: The patient was admitted to the hospital for observation and ongoing pain management due to her inability to bear weight. Fourteen hours into admission, she developed a fever and purpura was noted on her lower extremities.  Based on her presence of a purpuric rash, arthralgias and 1+ proteinuria in the setting of febrile illness, she was diagnosed with Henoch-Schonlein Purpura (HSP). She did not develop GI symptoms during admission. Her pain and swelling improved on the following day and she was discharged home with close follow-up by her primary care pediatrician.

For those wishing to read more about the variability of the clinical presentation of HSP, here is a case review of 254 children presenting over three years at 2 institutions.

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.

Brian Lee
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