Hot Seat #149: Denouement

Posted on: April 9, 2020, by :

The case: a 9mo healthy boy presenting with fever and great toe redness concerning for cellulitis vs osteomyelitis.

Here’s how you answered the questions:

 

Discussion: In a child who looks sick, most would obtain initial blood work, including blood culture, CBC ,and inflammatory markers. For imaging for this patient, most would also obtain an x-ray, with smaller numbers also obtaining an ultrasound. A handful of fellows would also pursue MRI while in the ED (assuming availability), likely to rule out osteomyelitis.

With mildly elevated inflammatory markers and normal imaging, the work up for this patient does not help in narrowing the leading differential: skin/soft tissue infection vs osteomyelitis. Given an unrevealing work up, the disposition for this patient then becomes a dilemma. Some fellows and attendings would send the patient home with PO antibiotics. Dr. Falk noted that the acute onset of the patient’s symptoms argue for cellulitis and discharge on PO antibiotics with good follow up is reasonable. Others noted that the patient’s initial acuity, age, and potential concerns for follow up warrant admission for antibiotics +/- MRI.

Denouement: Patient was given a dose of clindamycin in the ED admitted to the hospitalist service, continued on clindamycin with improvement in redness and no subsequent fevers. Orthopedics was consulted and did not recommend MRI given improvement on clindamycin alone. Discharged with presumed diagnosis of cellulitis.

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Mary Beth Howard
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