Case by Brittany Fitzpatrick MD, CNH PEM Fellow

6 yo F with non-verbal autism who presents with inability to bear weight x 4 days. She is here with her mother, who reports that she started having some difficulty with walking about a week ago and seemed not to want to bear weight on her left leg and needed to be carried. At onset, she had a one-time tactile fever and was seen at urgent care the next day, where XR of the left hip and knee were negative.  Yesterday, Mom found her on the ground after she fell out of bed. Since the fall, she seems to be in significant pain with movement of her right leg that does not improve with Tylenol. She presents today to the ED due to continued inability to bear weight bilaterally, with progressive worsening of her right leg pain.

History of a fever with full body rash about 1 month ago, including face, trunk, extremities, hands, and soles. RST negative, resolved without antibiotic treatment. No further fevers. No URI symptoms. PO, UOP, and BMs at baseline.

T: 36.9 HR: 108 RR:18 BP: 107/76 SpO2: 97%

General:  Alert.  cooperative. 
Skin:  Warm.  dry.  intact. Healed scarring from papular rash to trunk and upper extremities
Head:  Normocephalic.  atraumatic.  
Neck:  Supple.  No tenderness.  
Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  
Ears, nose, mouth and throat:  Oral mucosa moist.  No pharyngeal erythema or exudate.  
Cardiovascular:  Regular rate and rhythm.  No murmur.  No gallop.  Normal peripheral perfusion.  
Respiratory:  Lungs are clear to auscultation
Gastrointestinal:  Soft.  Nontender.  Non distended.  
Musculoskeletal:  Moving all extremities. Active ROM decreased of bilateral LE. R hip rotated externally at rest. Grimace with passive ROM of bilateral hips R>L. Tenderness of b/l hips, R>L. No swelling. No deformity. Normal passive ROM of bilateral knees and ankles. Stable pelvis.
Neurological:  Normal sensory observed.  normal motor observed. Gait not observed secondary to pain. Developmentally delayed.

XR negative for acute fracture. On reassessment there is no significant change in patient VS or pain level. She is still unable to bear weight to lower extremities.

US: Left greater than right hip effusions

Sent: CBC, CMP, ESR, CRP, Lyme, blood culture

Results: ESR: 52 (elevated), CRP: 1.16 (normal)

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