Cases

Case 1
A 14-yaer-old boy presented with fever of 1 month duration. Fever low grade, mostly in the evening. NO cough,
chest pain, dyspnea, weight loss, night sweats, dysuria, pain abdomen, myalgia, joiunt pains, no rashes, bleeding
from gum, no skin lesions. Was treated by a doctor, but fever tend to recur. While in the hospital, the patient
complained of severe pain in the knee and left ankle pain. This pain he had during last 6 months, he took
analgesics, the pain disappear, but to reappear later. hR82, regular B/P 110/70 Pulmo, Cor-N/.
Spleen palpable 2sm below left costal margin. Liver not palpable
Joints exam: Left ankle and knee joints swollen, warmth+, tenderness in the joint line, movements restricted due
to pain in the above joints. Other joints appear normal.
CBC: Hb- 9 grams ESR- 25/45 Platelets- 1.5 000 RBC-4 million. <>Urea- 35 mg Creatinine- 1.0 mg

1. Summary
2.Additional info
3. Differential
4. The most likely diagnosis
5. Treatment
Case 1
A 14-yaer-old boy presented with fever of 1 month duration. Fever low grade, mostly in the evening. NO cough,
chest pain, dyspnea, weight loss, night sweats, dysuria, pain abdomen, myalgia, no rashes, bleeding from gum, no
skin lesions. Was treated by a doctor, but fever tend to recur. While in the hospital, the patient complained of
severe pain in the knee and left ankle pain. This pain he had during last 6 months, he took analgesics, the pain
disappear, but to reappear later. hR82, regular B/P 110/70 Pulmo, Cor-N/.
Spleen palpable 2sm below left costal margin. Liver not palpable
Joints exam: 1. Left ankle and 2 and 3 knee joints swollen, warmth+, tenderness in the joint line, movements
restricted due to pain in the above joints. Other joints appear normal.
CBC: Hb- 9 grams ESR- 25/45 Platelets- 1.5 000 RBC-4 million. <>Urea- 35 mg Creatinine- 1.0 mg

1. Summary
2. Additional info -
3. Differential
4. The most likely diagnosis
5. Treatment
A 14-yaer-old boy presented with fever of 1 month duration. Fever low grade, mostly in the evening. NO cough, chest pain, dyspnea,
weight loss, night sweats, dysuria, pain abdomen, myalgia, no rashes, bleeding from gum, no skin lesions. Was treated by a doctor,
but fever tend to recur. While in the hospital, the patient complained of severe pain in the knee and left ankle pain. This pain he had
during last 6 months, he took analgesics, the pain disappear, but to reappear later. hR82, regular B/P 110/70 Pulmo, Cor-N/.
Spleen palpable 2sm below left costal margin. Liver not palpable
Joints exam: 1. Left ankle and 2 and 3 knee joints swollen, warmth+, tenderness in the joint line, movements restricted due to pain
in the above joints. Other joints appear normal.
CBC: Hb- 9 grams ESR/CRP- 25/45 Platelets- 1.5 000 RBC-4 million. <>Urea- 35 mg Creatinine- 1.0 mg

1. Summary
2. Additional info -
History Investigations:
-RF and ANA
- Ask about limping and stiffness -viral serology – CMV EBV, blood culture
- History of sore throat, URI, travel -Ultrasound X-ray or MRI
- Family history of arthritis, psoriasis, IBS, acute iritis -Screen for uveitis
-ECG and echo
A 14-yaer-old boy presented with fever of 1 month duration. Fever low grade, mostly in the evening. NO cough, chest pain, dyspnea, weight loss, night sweats, dysuria, pain
abdomen, myalgia, no rashes, bleeding from gum, no skin lesions. Was treated by a doctor, but fever tend to recur. While in the hospital, the patient complained of severe
pain in the knee and left ankle pain. This pain he had during last 6 months, he took analgesics, the pain disappear, but to reappear later. hR82, regular B/P 110/70 Pulmo,
Cor-N/.
Spleen palpable 2sm below left costal margin. Liver not palpable
Joints exam: 1. Left ankle and 2 and 3 knee joints swollen, warmth+, tenderness in the joint line, movements restricted due to pain in the above joints. Other joints appear
normal.
CBC: Hb- 9 grams ESR/CRP- 25/45 Platelets- 1.5 000 RBC-4 million. <>Urea- 35 mg Creatinine- 1.0 mg
1. Summary
2. Additional info -
3. Differential –
What kind of findings the patient has ?

Fever, sever pain rather than swelling and limping, 3 joint affected, generalized lymphadenopathy –
splenomegaly, mild anemia, ESR and CRP elevated, PLT – thrombocytosis
- RF negative – may be low grade fever, BUT it is polyarticular onset JRA – 5 or more affected joints
- Other types of arthritis Oligo articular JIA: NO fever, NO Systemic findings, occurrence more asymmetrical, present joint swelling more than limping
- RF positive – more hands arthritis, rheumatoid nodules, RF +, Erosion on X ray
- Chronic septic, EBV infection, CMV infection, Lyme, tuberculosis less reactive arthritis (because of duration), Rheumatic fever – NO renal failure or
heart damage.
- Malignancy – leukemia, lymphoma BUT No night sweat, weight loss, bruising and bleeding.
- SLE – specific rashes and ANA?
- SBI But – no weight loss and intestinal symptoms
- Vasculitis – excluded because of NO rashes and duration is long
A 14-yaer-old boy presented with fever of 1 month duration. Fever low grade, mostly in the
evening. NO cough, chest pain, dyspnea, weight loss, night sweats, dysuria, pain abdomen,
myalgia, no rashes, bleeding from gum, no skin lesions. Was treated by a doctor, but fever tend
to recur. While in the hospital, the patient complained of severe pain in the knee and left ankle
pain. This pain he had during last 6 months, he took analgesics, the pain disappear, but to
reappear later. hR82, regular B/P 110/70 Pulmo, Cor-N/.
Spleen palpable 2sm below left costal margin. Liver not palpable
Joints exam: 1. Left ankle and 2 and 3 knee joints swollen, warmth+, tenderness in the joint
line, movements restricted due to pain in the above joints. Other joints appear normal.
CBC: Hb- 9 grams ESR/CRP- 25/45 Platelets- 1.5 000 RBC-4 million. <>Urea- 35 mg Creatinine- 1.0 mg
1. Summary
2. Additional info -
3. Differential
4. The most likely DS – Systemic arthritis
A 14-yaer-old boy presented with fever of 1 month duration. Fever low grade, mostly in the
evening. NO cough, chest pain, dyspnea, weight loss, night sweats, dysuria, pain abdomen,
myalgia, no rashes, bleeding from gum, no skin lesions. Was treated by a doctor, but fever
tend to recur. While in the hospital, the patient complained of severe pain in the knee and
left ankle pain. This pain he had during last 6 months, he took analgesics, the pain
disappear, but to reappear later. hR82, regular B/P 110/70 Pulmo, Cor-N/.
Spleen palpable 2sm below left costal margin. Liver not palpable
Joints exam: 1. Left ankle and 2 and 3 knee joints swollen, warmth+, tenderness in the joint
line, movements restricted due to pain in the above joints. Other joints appear normal.
CBC: Hb- 9 grams ESR/CRP- 25/45 Platelets- 1.5 000 RBC-4 million. <>Urea- 35 mg Creatinine- 1.0 mg
1. Summary
2. Additional info -
3. Differential
4. The most likely DS – Systemic arthritis
5. Treatment – Oral steroids, Intra-articular corticosteroids
Case 2
Aiden a 5 year old boy brought in to the clinic today by his mother. She has been
concerned about Aiden for the past few months. She has noticed that he has become
increasingly tired. He no longer enjoys playing outside and his kindergarten teacher has
noticed a decrease in his energy level. Aiden was taken to a local walk-in clinic twice in
the last few months but each time was reassured that everything was okay. When you
ask about any other symptoms, she mentions that she has noticed that Aiden has been
limping for the last 2 weeks. On examination you notice some pallor, pale conjunctiva
and a mild limp effecting his left leg. The rest of the examination is unremarkable. The
CBC and differential showed pancytopenia. Based on these findings, a peripheral
smear was also ordered.
1.Summary
2.Additional info
3. Differential
4.The most likely diagnosis
5.Treatment
Case 2
Aiden a 5 year old boy brought in to the clinic today by his mother. She
has been concerned about Aiden for the past few months. She has
noticed that he has become increasingly tired. He no longer enjoys
playing outside and his kindergarten teacher has noticed a decrease in
his energy level. Aiden was taken to a local walk-in clinic twice in the
last few months but each time was reassured that everything was okay.
When you ask about any other symptoms, she mentions that she has
noticed that Aiden has been limping for the last 2 weeks. On
examination you notice some pallor, pale conjunctiva and a mild limp
effecting his left leg. The rest of the examination is unremarkable. The
CBC and differential showed pancytopenia. Based on these findings,
a peripheral smear was also ordered.
1.Summary
Case 2
Aiden a 5 year old boy brought in to the clinic today by his mother. She has been concerned about Aiden
for the past few months. She has noticed that he has become increasingly tired. He no longer enjoys
playing outside and his kindergarten teacher has noticed a decrease in his energy level. Aiden was taken to
a local walk-in clinic twice in the last few months but each time was reassured that everything was okay.
When you ask about any other symptoms, she mentions that she has noticed that Aiden has been limping
for the last 2 weeks. On examination you notice some pallor, pale conjunctiva and a mild limp effecting his
left leg. The rest of the examination is unremarkable. The CBC and differential showed pancytopenia.
Based on these findings, a peripheral smear was also ordered.
1.Summary
2.Additional info
History
- Ask about night sweat, anorexia, bleeding in the past
- Family history including malignancy and inherited condition
Investigations:
- Blood electrolyte, levels of uric acid, potassium, phosphorus, calcium, and lactate dehydrogenase (LDH),
ANA, RF
- bone marrow aspirate and biopsy performed under sedation and Immunophenotyping
- Cytogenetic and Molecular Studies
-
Aiden a 5 year old boy brought in to the clinic today by his mother. She has been concerned
about Aiden for the past few months. She has noticed that he has become increasingly tired. He
no longer enjoys playing outside and his kindergarten teacher has noticed a decrease in his
energy level. Aiden was taken to a local walk-in clinic twice in the last few months but each time
was reassured that everything was okay. When you ask about any other symptoms, she mentions
that she has noticed that Aiden has been limping for the last 2 weeks. On examination you notice
some pallor, pale conjunctiva and a mild limp effecting his left leg. The rest of the examination is
unremarkable. The CBC and differential showed pancytopenia. Based on these findings, a
peripheral smear was also ordered.
1. Summary
2. Additional info
3. Differential
What kind of findings the patient has ?
Weakness, limping – because of bone marrow infiltration, pallor, pale conjunctiva, pancytopenia
- JIA (oligoarthicular form)– BUT no stiffness, and changes in CBC as pancytopenia
- Aplastic anemia and Anemia Fanconi
- Parvovirus 19 and EBV
- Pediatric ostheomielitis
Aiden a 5 year old boy brought in to the clinic today by his mother. She has been
concerned about Aiden for the past few months. She has noticed that he has
become increasingly tired. He no longer enjoys playing outside and his
kindergarten teacher has noticed a decrease in his energy level. Aiden was taken
to a local walk-in clinic twice in the last few months but each time was reassured
that everything was okay. When you ask about any other symptoms, she
mentions that she has noticed that Aiden has been limping for the last 2 weeks.
On examination you notice some pallor, pale conjunctiva and a mild limp
effecting his left leg. The rest of the examination is unremarkable. The CBC and
differential showed pancytopenia. Based on these findings, a peripheral smear
was also ordered.
1. Summary
2. Additional info
3. Differential
4. The most likely diagnosis - Acute lymphoblastic leukemia
5. Treatment: Chemotherapy.