Hot Seat #51: 5yo M p/w bilateral LE pain and fever
Posted on: February 16, 2015, by : Anne Whitehead
by Anne Whitehead, Inova Children’s Hospital
with Joelle Simpson, Children’s National
The Case
A 5 yo previously healthy African American boy presents with bilateral lower extremity pain and tactile fever. Pain is localized to the thighs and hips bilaterally. It started yesterday, and was initially mild, and well controlled with acetaminophen, but progressed over 2 days to be so severe he was unable to walk. Tactile fevers reported x 2 days. Also c/o lower abdominal pain for one day, associated with constipation, no bowel movement for 5 days. No reported back pain or incontinence. No history of trauma. No visible skin changes. Slightly decreased PO, nl urine amount and color.
PMHx: Eczema. No current PCP due to multiple moves, irregular hx primary care but imm UTD incl 4 yo shots per mom (at last WCC)
Social Hx: lives with mom, dad and siblings. No recent travel.
ROS: No upper extremity pain. No nausea or vomiting. No cough, runny nose, chest pain, or shortness of breath. No back pain, no unusual bleeding or bruising. Eczema, but no other rashes.
PE: BP 154/84, Pulse 143, Temp 39.1 °C, Resp 26, SpO2 98% on RA
Constitutional: Crying in pain. After IV narcotic-> comfortable and sitting in bed conversing
HEENT: WNL
Skin: no rashes/erythema
Respiratory/Chest: clear and equal to auscultation bilaterally
Cardiovascular: Regular rate and rhythm. No murmur.
Abdomen: soft mod ttp in bilat lower quadrants with no masses. No R/G. No HSM
MSK: neck normal. exquisitely tender to palpation throughout bilateral thighs. Pain with passive ROM hips bilat, though it is hard to tell if this is from thighs or hips. No tenderness over lateral hips. Back nontender without swelling.
Neurological: CNII-XII intact, sensation intact throughout, strength 4/5 in LEs though seems to have more giveway weakness secondary to pain, reflexes 2+ throughout LEs. No clonus. Refuses to walk.
Lymphatic: No LAN
You order initial labs and IV pain medications.
Questions for you:
Re-examination
Labs return
CBC: WBC 16 Hb 9.9 Hct 29.1 plt 291 MVC 66 retic 2.3 neutrophils 62 bands 3
BMP: normal except for mild hyponatremia- 131
ESR: 36
CRP: 2.3
CK WNL
Anything else you’ve ordered is pending…
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
I would leave the room being most concerned that there is a problem localized to the spinal cord, given the bilateral nature of the symptoms, and knowing that the child needs to be admitted with a Neurology consult in the ED.
Diagnoses to consider: Guillain-Barre would explain the pain and inability to walk, but the reflexes are intact in the lower extremities. Tranverse myelitis would explain the symptoms fully—pain, weakness, usually accompanied by paresthesias, and fever. A mass impinging on the spinal cord would also explain the pain and inability to walk, with an epidural bleed or abscess in the lower cord being lower on my ddx (no hx of trauma and inflammatory markers not very elevated).
An important part of the exam that needs to be added is the rectal tone- one of the few situations a rectal exam is required (and constipated babies). Poor rectal tone will strongly support the above diagnostic concerns. If this is the case, I would leave a catheter in his bladder as well.
My next steps: labs as done, BCx, and urgent MRI of the spine.
Love the response! My impression is a little different.
This sounds like bogus to me, unless his BP is really elevated or he has true weakness.
I think what jumps out in my mind is conversion disorder vs. transverse myelitis vs. fever response (myalgias without myositis) vs. psoas abscess.
you really need to determine if there is WEAKNESS or just pain. very very very different.
but anytime kids have inability to walk and i’m even considering a neurologic process, I think it’s time to play LOCALIZE THE LESION
let’s play the feud. muscle, peripheral nerve, NMJ, AHC, brainstem, cerebellum, cortex.
–Muscle – if the CPK is normal, then this isn’t rhabdo, dystrophy, pyomyositis, etc. and most global muscle problems are proximal (trunk, etc)
–Peripheral Nerve – this should really be distal. GBS, etc. so i would expect sensory loss, weakness, tingling of legs. not really pain.
–NMJ – (botulism or myasthenia gravis) and both should cause task-specific fatigue
–Spinal Cord – classically, an epidural hematoma or mass or abscess in the cord should cause a spinal level and weakness….i wouldn’t really expect pain, although transverse myelitis is such as spotty disease i could see how a few patches of demyelination could cause pain. but i think it’s weird for them to be bilateral without true sensory loss or other spinal signs. so i think this is a stretch. but i agree that it’s ESSENTIAL to test for anal tone, reflexes, sensation, etc like Jen alluded to.
–AHC (LMN) – SMA, polio, charcot-marie tooth. this should have absent reflexes and weakness, not really pain. fasiculations are classic
–CEREBELLUM – really should cause ataxia, tremor, vertical nystagmus
–CORTEX – anything causing pain or weakness should be contralateral, not bilateral
So my approach would be to:
–really tease out if this is weakness or pain and get a good reflex and anal exam (signs of peripheral nerve or spinal disease)
–give the kid a bunch of fluids and toradol. if that makes it go away, this isn’t transverse myelitis or syringomyelia etc or a spinal mass.
–repeat a BP – not sure why his BP is 150s? needs investigating. if true, this definitely argues against conversion disorder.
–i don’t think an emergent MRI of the spine is indicated unless there are slam dunk spinal signs such as a sensory level or loss of bowel/bladder tone or surgical history in that neighborhood. but given that the CRP is elevated i think it’s reasonable to admit for repeat neuro exams and if no change (or signs to suggest otherwise, (aka conversion) that an MRI brain/spine is appropriate. It’s hard to just do the spine because if he does have transverse myelitis or patchy white matter disease you want to see if it extends into the brain even without clinical symptoms. transverse myelitis is associated with recent viral infection but not necessarily high fevers concurrently, this makes me suspicious.
–if he lacks the emergent MR criteria, i think it’s reasonable to do an US or CT of his belly since he has lower abdominal pain and thigh pain. hint: psoas abscess, although would be weird to be bilateral.
Just a wild thought, could this be an undiagnosed sickle cell patient with a pain crisis and fever? Pt is anemic, low MCV (combined sickle cell/ thalamsemia vs iron vs other) and has bilateral leg pain. Multiple PCPs etc. Might be worth at least asking about birth history/ newborn screen/ fam history etc. and considering an HGB electrophoresis.
It seems the exam is very difficulty, which is often the case. I would also involve child life or other techniques (letting parents examine while I observe) to help better localize tenderness (back, abdomen, hip, thigh). This would be extremely helpful in focusing my additional work up.
I appreciate the prior comments on this case and agree with all that was said above. As written above, this case focuses on acute onset of lower extremity and abdominal pain in a 5yo. The exam says that the symptoms are alleviated by narcotics and the patient’s effort in demonstrating strength vs weakness appears to be impacted by pain.
If this were presented to me by a trainee, I would definitely focus on doing a rectal exam and really identifying whether this patient has true weakness bilaterally versus an exam limited by pain. (The former would immediately spiral me into a detailed spinal cord/CNS evaluation to explain a bilateral LE neurological deficit). Also, in my attending addendum to the physical exam I would document how this patient sits at rest – ie what is his natural position of comfort – with hips abducted? Refusing to sit up? laying down only? Will he get on his knees to play with a toy when child life comes in the room?
Since Dave did an excellent job already going through the evaluation of weakness at this level, I will focus on my approach to an evaluation of the pain.
Pain assessment in a young child can be PAINFUL. However, I find it helpful to try to decipher the true source of pain – ie skin, muscle, bone, joint, nerve etc AND the best possible etiology for the pain – ie trauma, infection, inflammatory, oncologic, referred. In this particular case, the idea that this might be referred pain is the front-runner in my mind. I say this because this child is otherwise well appearing, without trauma or other historical risk factors such as unusual exposures, travel or lack of vaccinations. I always remember that hip pain can refer to the knee, back pain can refer to the hip and radicular pain from the spine can present with pain down the leg.
I would image this patient initially while waiting for labs – starting off with a basic Abd XR – no BM for 5 days – presuming I have normal rectal tone on exam, I want to know if he is blocked due to functional constipation or a possible mass. I probably would have done toradol instead of morphine for pain because I know I want to preserve the best possible neuro exam/effort that I can obtain. (Plus morphine doesn’t help the potential constipation issue – although I know one dose should be ok). I would also get a manual recheck of the BP (kinda feels like a red herring but I won’t ignore it).
Now that I know what the labs show, I make a mental note of the microcytic anemia and mod elevation in inflammatory markers. I am reassured with the CK and remove “muscle” from my differential list. Infection and inflammatory conditions have inched higher on my possible etiologies.
I would absolutely get a repeat exam within an hour of antipyretics noting what the exam is like when the fever is gone and document the patient’s ability to tolerate oral hydration and void spontaneously. Why? Because the lower abdomen has one main organ in boys – the bladder! (I have had a case of delayed posterior urethral valves in a patient during residency who also said that they had their normal urine volume – just not normal with the rest of the population). I want an US of the GU system especially evaluating for any signs of obstruction. An obstructive process in the GU system could explain lower abd pain, fever (higher risk for infection) and possibly discomfort with ambulation as described in this patient.
If the above less invasive and cost effective diagnostic tests are unremarkable, I would proceed to more detailed imaging of the lower abdomen such as CT. I would absolutely agree with emergent MR if my exam pointed more to weakness and not just pain on repeat exams.
I know I didn’t really discuss much about this being primary musculoskeletal pain but that is still be on the differential. That can be a BROAD work up. The Children’s Hospital of Wisconsin has an AWESOME clinical algorithm for work up of a child with lower extremity musculoskeletal pain. See website: http://www.chw.org/~/media/Files/Medical%20Professionals/Medical%20Care%20Guidelines/Lower_Extremity_Pain.pdf