Case: a 10 yo F presenting with fever and swollen left knee

Here’s how you answered the questions:

Discussion:

This case presented multiple clinical dilemmas ripe for discussion. When the patient arrives in shock, the initial question is how aggressive to be. Most agreed that the patient needed aggressive fluid resuscitation, but calling a “code sepsis” in the ED and obtaining the associated blood gas and empiric antibiotics may not be indicated immediately. The timing of when to give antibiotics is up for debate, and most agreed they may not give antibiotics immediately, but with signs of infection of labs and joint aspirate, in addition to patient’s clinical status, broad spectrum antibiotics are warranted.

In a patient with a knee swelling and exam and OSH imaging consistent with effusion, many of those in the room argued for attempting to tap the joint ahead of waiting for the US and/or orthopedics. This becomes less of an issue when the patient is found to have DVT.

The patient’s persistent tachycardia despite fluid resuscitation, as well as hypoxia and tachypnea are concerning for a pulmonary embolism. Following Wells’ criteria for risk of PE, her score is 7.5 (+3 for clinical DVT, +3 PE is #1 diagnosis or equally likely, +1.5 HR >100), putting her at high risk for PE so people unanimously felt that a CT PE while initiating anticoagulation is warranted.

Clinical probability assessment: High >6.0, Moderate 2.0 – 6.0, Low <2.0

Ultimately, the patient was found to have thrombophlebitis as a complication of osteomyelitis and hyper-coagulability. She was admitted to the PICU, continued on anticoagulation and later transferred to the floor. Her final diagnosis is currently pending.

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