By Dr. Christina Rojas, Children’s National Medical Center

You start an overnight shift and got sign out on a 3 y/o female with sickle cell anemia (HbSS) who presented with fever, puffy eyes, and bilateral extremity pain. Fever developed this morning, Tmax 38.5. Puffy eyes started yesterday. Extremity pain is bilateral in all four extremities and non-focal. Parents have been giving ibuprofen for pain with moderate relief.

No history of trauma. No daily medications or environmental allergies. No new foods, exposures, or travel. The patient is not on penicillin prophylaxis and has not received pneumovax or meningococcal vaccines. Has a history of osteomyelitis of R hip last year that resolved with IV antibiotics.

Initial Physical Exam: T 38.3 HR 136 RR 30 BP 112/71 SpO2 99%
General: appears uncomfortable
Head: normocephalic, atraumatic
Eyes: significant periorbital edema with erythema; briefly able to visualize conjunctiva which appear normal
Mouth: moist oral mucosa, no intraoral lesions
Respiratory: clear lung sounds bilaterally, no increased work of breathing
CV: tachycardia, regular rhythm, no murmurs
Abdomen: soft, non-tender, non-distended
MSK: non-focal tenderness in all extremities, full ROM, no swelling, no deformities
Neuro: no focal neurologic deficits, normal mental status, moving all extremities equally and spontaneously
Skin: No rashes

The following tests were already obtained:
CBC: WBC 23.2, HgB 9.6, platelets 369, 4% bands, 16.91 ANC (ref range 1.60 – 8.29)
CMP: Na 133, K 4.5, Cl 95, CO2 18, BUN 5, Cr 0.15, bilirubin 1.8, AST 93, ALT 27
UA: 3+ ketones, otherwise normal

She has received ceftriaxone empirically as well as cetirizine and ibuprofen. When you evaluate her for the first time, her eyes continue to be very swollen and she is febrile. Parents ask about additional medications that can be given.

You wonder if this patient needs additional imaging and call MRI to check availability. They say they would not be able to image the patient for at least 8 hours.

CT orbits with and without contrast is completed which demonstrates bilateral subperiosteal fluid collections along the roots of both orbits, concerning for hematoma versus infectious etiology.