By Aditi Ghatak-Roy, INOVA Children’s

10-year-old female with no medical history presents to the ER with 6 days of daily fevers. Highest temperature of 104 orally and controlled with Tylenol and Motrin. Family also mentions right leg pain. Family noticed she was limping about 1 week ago and seemed to favor the right leg. It is difficult for the patient to describe the pain – she says it’s sharp sometimes at the right knee when she straightens the leg or puts weight on it. That sensation has subsequently disappeared as of 2 days ago. Today she denies leg pain and is no longer limping.

Immunizations up to date. COVID vaccination #2 1.5 weeks prior. No history of trauma. No sick contacts. No home chronic home medications.

ROS:

+Decreased appetite. Also reports a rash that recently appeared on bilateral axilla. No URI symptoms, no GI/GU symptoms.

PE:

VS: T100.9 (38.3), HR 124, BP 118/76, RR 24, SpO2 100%, Wt 60kg

HEENT: Clear conjunctiva. Clear oropharynx, no oral lesions, or mucosal changes.

CV: No murmurs, normal cap refill.

Resp: CTAB

Abdomen: Soft, nontender, no HSM.

MSK: Grossly normal ROM of bilateral hips, knees, ankles. No localizing pain with active/passive rotation, flexion, extension of right hip, knee and ankle. No joint effusions. No rashes, edema. Normal gait. Brisk DP/PT pulses.

Neuro: 5/5 strength x 4 extremities, normal sensation, normal gait.

Skin: Erythematous, non-blanchable, non-pruritic scattered homogenous papules of b/l axillae

On reassessment, fever resolved with Tylenol. During change into gown, patient and family
members noticed that she has developed a new rash of the groin area. Features are similar to
the rash of the axillae. POCUS of hip by ED team with no hip or knee effusion; no areas
amenable to arthrocentesis. She continues to appear comfortable with no gait abnormalities.

Labs:

(ESR normal < 20 mm/hr)

(CRP normal < 0.8 mg/dL)

Respiratory viral panel: negative

Right hip and knee XR: negative