In summary, your patient has fever for 6 days, arthralgia for 3-4 weeks
of knees & ankles without evidence of true arthritis or functional
limitation, URI for 7-10 days, and a normal exam without a source
barring some irritability and tender cervical nodes (I assume
I would include in the differential diagnosis the following:
1. The "arthralgia" for a month is bothersome. My concern is does the
child have an occult hematologic malignancy(leukemia, lymphoma etc) with
bone pains which is masquerading as joint aches.
2. Atypical Kawasaki's has been described with cases like these with
fever> 5days, arthralgia, cervical lymphadenopaty and irritability. The
absence of muco-cutaneous changes, bilateral lymphadenopathy and the
joint pains preceding the fever make it "atypical." Our cardiologists
have described some of these cases ending up with coronary aneurysms!
3. Systemic onset JRA (or other rheumatological diseases like SLE). This
would require longer than 4-6 weeks of fever without other obvious
causes to confirm the diagnosis. Fleeting rashes, organomegaly, pallor
would help but may not have declared itself yet.
4. Serum sickness like illness with fever, lymhadenopathy & arthralgia
is possible. Any recent antibiotic history like cefaclor or recent
5. A protracted viral illness is still the most likely. Considerations
include EBV, CMV, parvovirus with joint symptoms. Watchful expectancy
would sort this out.
6. SBE is possible with prolonged fever and arthralgia. The absence of
murmur, pallor, splenomegaly would go against it. Any splinter
hemmorhages or clubbing? With this history of SVT ,"unknown" reason for
ECMO and room air sats of 96% I wonder if this patient has a
structurally normal heart?
7. Cat scratch fever can give fever and adenopathy. Any kitten exposure?
........the list goes on
Given the above, I would do minimally do a CBC, UA (occult vasculitis,
SBE can give hematuria), ESR, CxR (look for mediastinal adenopathy) & ?
If all above labs are normal I would discharge, recheck in 2-3 days,
with fever "diary." Let time declare the illness!
Hope that helps. Let us know the outcome.
> -----Original Message-----
> From: Randolph J Cordle [SMTP:[log in to unmask]]
> Sent: Tuesday, February 17, 1998 10:49 PM
> To: Multiple recipients of list PED-EM-L
> Subject: Child with fever
> I am curious how some of you would handle this case.
> A 3 yo presents with complaint of fever for 6 days. Fever maximum
> about 102.5
> each day on ibuprofen and acetominophen. Mother states child has had
> aches in the knees and ankles for the last 3-4 weeks. She has never
> had any
> other joint findings. She has also had clear rhinnorhea for the last
> days. She has had a mild occasional nonproductive cough but no
> distress. She denies any nausea, vomiting, diarrhea, rash, headache,
> pain, strange behavior, urinary symptoms, or vaginal discharge. She
> had some
> vague complaint of general abdominal discomfort a day or two ago but
> currently. Child is eating, drinking and voiding normally. Her past
> history is significant for SVT and ECMO after birth for an unknown
> Family history is significant for lyme disease only.
> Her vital signs are normal with the possible exception that her
> temperature is
> 99.5. Oxygen saturation was 96% on RA.
> Physical Exam:
> Well hydrated, well developed child in no acute distress. Sitting on
> bed with
> mother. She was somewhat irritable but easily consolled.
> PERRL, EOMI, No conjunctival findings.
> Normal ear drums and canals
> Normal nasopharynx
> Normal oropharynx
> No meningeal findings. 6-7 <1cm tender mobile anterior cervical
> Lungs normal
> Heart normal
> Abdomen entirely benign
> Extremities- Normal- specifically no rash, fusiform swelling, skin
> edema, joint findings. Pulses intact throughout.
> What work up would you do if any?
> What diagnosis would you give?
> What treatment would you give if any?
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