Author Affiliations: Queen's University, Kingston (Ms Rana) and Department of Pediatrics, The Hospital for Sick Children, Toronto (Drs Alterkait and Weinstein), Ontario, Canada.
A 12-year-old boy with nonverbal autism developed a 2-month history of petechiae and bruising followed by worsening musculoskeletal pain and refusal to walk. There was no preceding history of trauma, fever, or visible joint swelling. On physical examination he was pale and agitated. His lower limb range of motion was limited, and he maintained 90° flexion of both knees and external rotation of his left hip with refusal to ambulate. Petechiae and bruising were noted on his lower extremities (Figure 1), and gingival bleeding (Figure 2) and alopecia were noted. Investigations revealed microcytic anemia (hemoglobin level, 9.0 g/dL; reference range, 12.0-16.0 g/dL; to convert to grams per liter, multiply by 10.0), a low serum iron level, and normal white blood cell and platelet counts. The peripheral blood smear was normal apart from features suggestive of iron deficiency, and the erythrocyte sedimentation rate was elevated (46 mm/h; reference range, 1-10 mm/h). Radiographs of the legs demonstrated only soft-tissue swelling and osteopenia. Dietary history revealed longstanding restricted food preferences limited to yogurt, pasta, oatmeal, and water.
Figure 1. Bruising (large arrow) and perifollicular petechiae (small arrow) on the lower leg.
Figure 2. Diffuse gingival inflammation and bleeding (arrows).
What is your diagnosis?
Thank you for submitting a comment on this article. It will be reviewed by JAMA Pediatrics editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 1
Customize your page view by dragging & repositioning the boxes below.
The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Original Article: Does This Adult Patient Have Septic Arthritis?
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.