0
Special Feature |

Picture of the Month—Quiz Case FREE

Eric J. Haas, MD; Linda Ernst, MD
[+] Author Affiliations

Section Editor: Samir S. Shah, MD


Arch Pediatr Adolesc Med. 2009;163(1):85. doi:10.1001/archpediatrics.2008.514-a.
Text Size: A A A
Published online

A previously healthy 3-year-old girl had 3 days of fever, decreased activity, and a limp. There was no antecedent trauma. She reported left hip pain and her mother noted an abnormal gait. On examination, the patient's temperature was 39.2°C. She had bilateral cervical lymphadenopathy with a prominent right-sided 2 × 2-cm anterior cervical lymph node with mild tenderness but no warmth or erythema. At her left hip, there was no tenderness to palpation, but range of motion was limited. The patient's peripheral white blood cell count was 13 400/μL (to convert to ×109/L, multiply by 0.001) with 36% segmented neutrophils. Her erythrocyte sedimentation rate was 72 mm/h, and C-reactive protein concentration was 3.2 mg/dL. Urinalysis, basic chemistry, and hepatic function testing results were within normal limits. Serologic tests for Bartonella henselaeantibodies did not reveal evidence of acute infection (IgM < 1:16; IgG, 1:128).

Computed tomography of the neck demonstrated multiple lymph nodes with focal necrosis (Figure 1). Computed tomography of the abdomen showed no hepatosplenic changes. However, magnetic resonance imaging revealed myositis of the left obturator internus and adductor longus muscles with abscess formation and bone marrow edema and enhancement in the left acetabulum (Figure 2). The patient was treated with intravenous clindamycin for presumed acute hematogenous bacterial osteomyelitis. During the next week, the patient's leg pain decreased and her gait improved. However, she remained febrile and her C-reactive protein concentration increased to 6.8 mg/dL. Biopsies of the lymph node (Figure 3A) and intramuscular fluid collection (Figure 3B) revealed the diagnosis.

Place holder to copy figure label and caption
Figure 1.

Computed tomography of the patient's neck with contrast. Multiple enhancing enlarged lymph nodes (arrow) with central necrosis and loss of tissue planes surrounding the nodes.

Graphic Jump Location

Place holder to copy figure label and caption
Figure 2.

Magnetic resonance imaging of the pelvis with contrast. A, Axial view. B, Coronal view. Myositis of muscles adjacent to left acetabulum (arrows) with osteomyelitis.

Graphic Jump Location

Place holder to copy figure label and caption
Figure 3.

A, Histologic section of the lymph node biopsy specimen showing effacement of normal lymph node architecture and replacement by granulomatous inflammation characterized by an outer rim of small lymphocytes and collections of epithelioid histiocytes with a pale eosinophilic appearance surrounding areas of suppurative necrosis (arrows) (hematoxylin-eosin staining, original magnification ×100). B, Histologic section of the needle biopsy specimen of left pelvic tissue showing a dense mixed inflammatory infiltrate composed of lymphocytes (far right) and collections of palisading epithelioid histiocytes (white arrows) surrounding areas of suppurative necrosis (black arrows) (hematoxylin-eosin staining, original magnification ×100). Inset, Warthin-Starry silver staining was performed and showed a few small rod-shaped organisms (arrow) (original magnification ×1000).

Graphic Jump Location

Figures

Place holder to copy figure label and caption
Figure 1.

Computed tomography of the patient's neck with contrast. Multiple enhancing enlarged lymph nodes (arrow) with central necrosis and loss of tissue planes surrounding the nodes.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Magnetic resonance imaging of the pelvis with contrast. A, Axial view. B, Coronal view. Myositis of muscles adjacent to left acetabulum (arrows) with osteomyelitis.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A, Histologic section of the lymph node biopsy specimen showing effacement of normal lymph node architecture and replacement by granulomatous inflammation characterized by an outer rim of small lymphocytes and collections of epithelioid histiocytes with a pale eosinophilic appearance surrounding areas of suppurative necrosis (arrows) (hematoxylin-eosin staining, original magnification ×100). B, Histologic section of the needle biopsy specimen of left pelvic tissue showing a dense mixed inflammatory infiltrate composed of lymphocytes (far right) and collections of palisading epithelioid histiocytes (white arrows) surrounding areas of suppurative necrosis (black arrows) (hematoxylin-eosin staining, original magnification ×100). Inset, Warthin-Starry silver staining was performed and showed a few small rod-shaped organisms (arrow) (original magnification ×1000).

Graphic Jump Location

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles