Hot Seat #181: 5-year-old with difficulty walking.

Posted on: December 12, 2021, by :

HPI:

5-year-old female with a non-verbal autism presents to the ED due to progressive refusal to bear weight over the past month.    

Patient was initially seen three weeks ago by her pediatrician for LLE pain. At that visit the CBC, CK, ESR, and CRP were all normal. She was incidentally found to have Vitamin D deficiency, and was started on Vitamin D 4000 IU/d. Two weeks ago, she was seen by orthopedics. At that time, she had x-rays of her left knee, left tibia/fibula, and pelvis which were all normal.

She presents to the ED one week later due to continued LLE pain and refusal to bear weight. On history mom reports a fall out of her stroller one week ago, but no other significant trauma. Mom denies any fevers/chills, weight loss, night sweats, rashes, vomiting, change in stool pattern, foul smelling urine, change in appetite, or joint swelling. Mom does not feel that she has had any neck pain or back pain. There is no recent travel. She takes no medications other than Vitamin D. No new stressors at home. She is UTD on immunizations.

ROS: as per HPI

Physical Exam:

VS: T 37.5 C, HR 133, RR 28, BP 100/60, SpO2 98% on RA

General:  Pt is alert, very upset while being examined which mother reports is baseline

Skin:  Warm.  Dry. No rashes.

Head:  Normocephalic.  Atraumatic.  

Neck:  Supple.  Trachea mid-line.  No obvious tenderness while being examined.  No cervical lymphadenopathy.  

Eye:  Pupils are equal, round and reactive to light.  Extra-ocular movements are intact.  Normal conjunctiva.  No discharge. 

Cardiovascular:  Regular rate and rhythm.  No murmur.  

Respiratory:  Lungs are clear to auscultation.  No respiratory distress.    

Chest wall:  No tenderness.  No deformity.  

Back:  No obvious tenderness on palpation of thoracic or lumbar spine, no step-offs, no bruising

Musculoskeletal:  Crying in pain on exam of all extremities, but appears to have increased crying and discomfort with left hip flexion. No obvious swelling or deformity of any joints or extremities. No distinct boney tenderness of any extremities. No bruising.

Gastrointestinal:  Soft.  Nontender.  Non distended.  

Genitourinary:  normal external GU exam

Neurological:  No focal neurological deficit observed.  Moving all extremities equally. Mild increased tone of lower extremities compared to upper extremities, which is his baseline per mom. Sensation appears intact (pulls away when tickled). Normal rectal tone.

She had an ultrasound of her hips which showed small right greater than left hip joint effusions with synovial thickening consistent with transient synovitis. She received a dose of Motrin in the ED. Mom felt that her pain improved slightly and was comfortable with discharge home with instructions to follow-up with her PCP.

She returned to the ED one week later due to continued LLE and refusal to bear weight. Mom was now concerned because she has developed decreased strength with fine motor movements in her upper extremities. For example, mom reports that she is no longer able to open a string cheese wrapper by herself. Mom also reports that she now has pain whenever she tries to straighten her legs. Her ROS is otherwise unchanged including no fever, no joint swelling, no vomiting, no change in bowel movements, no change in appetite, no abdominal pain, no rashes, no urinary symptoms, no URI symptoms.

Physical Exam:

VS: : T 36.1 C, HR 125, RR 25, BP 98/56, SpO2 100% on RA

General: She screams and becomes agitated anytime a medical provider is in the room, but she is resting comfortably when she is alone with mom.

MSK: laying on bed with knees flexed, unwilling to straighten legs, cries when legs are touched, bilateral lower extremities have increased tone compared to upper extremities (baseline), appears to have 5/5 strength in upper and lower extremities (she kicks and pushes providers away), but unable to assess fine motor movements in upper extremities due to poor cooperation, when picked up off the bed she cries and holds her legs in a flexed position, unwilling to bear any weight on her lower extremities; no bruising or swelling of the extremities; unable to elicit reflexes in upper or lower extremities.

Repeat laboratory studies were obtained (CBC, BMP, ESR, CRP, and CK)- all were normal. Orthopedics recommended X-ray of the cervical spine due to concern for upper extremity weakness which was also normal. Neurology recommended LP and MRI Brain/Spine due to concern for progressive neurological symptoms.

Brian Lee
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