Clinical case 008: Paediatric Pain in the legs

5 year old girl presents with mum to the ED with a 3 day history of “pain in the legs”.  Initially thought it was due to her newly acquired zeal for hip-hop dance, however it is getting worse despite rest…  No relief from ibuprofen, pain is not well localised but quite symmetrical in both thighs and calves.  Mum states she has been well aside from a bout of diarrhea a few weeks ago that resolved quickly.  Otherwise healthy, active girl, fully immunised and developing normally.  No fevers, no travel, no history of trauma

I love Paeds because it is the last bastion of good old-fashioned clinical medicine.  Not many fancy tests or politicking.  You can still make the “end-of-bed” diagnosis if you take the time to look!

Mum carries her into the exam room. As the girl walks to the bed she looks like she is in pain, she ‘waddles’, holding onto furniture to help herself.

On exam, she has normal ROM in all her joints, no focal arthritis, no palpable tenderness, no hot areas.  Her power is within normal limits, though restricted by pain. No rash

No tics or fasciculations. Tone normal. On testing her deep-tendon reflexes (yes we do this in kids!) she has almost no knee jerk and absent ankle jerks bilaterally. Her cranial nerves, including bulbar signs and pupils are all normal. Normal sensation

Never forget the neuro exam in kids! It is usually easier than in adults as you aren’t finding all the ‘old’ signs, what you find is usually the real deal.

Paediatric Guillane-Barre syndrome is likely

Also consider a spinal cord lesion – though less likely without trauma or sign of an abscess / infection.

Maybe tick-bite paralysis – can’t hurt to look for a tick hidden somewhere!

POst-viral myositis does cause similar pain, but I would not expect arreflexia.  You can check a CK to exclude it.

If you said polio – you are likely the oldest ever visitor to this site, or have recently arrived from Africa (or you are a very keen Med Student!)

Rare, however most common age group is 12 mths – 4 yrs (1.7/100,000) Antecedent illness eg. URTI, gastro (esp. Campylobacter) triggers an immune –mediated demyelinating polyradiculopathy Occurs in epidemics in northern China Follows a triphasic course; 3 – 6 weeks Mortality arises from respiratory failure and autonomic instability mainly Most recover completely, some left with subclinical weakness, rarely permanent disability

Required for diagnosis:  Progressive weakness in > 1 limb  or Areflexia or marked hyporeflexia

Supportive features:   Onset over days to weeks,  Relative symmetry and mild sensory loss, Pain / discomfort in extremities at onset – esp. in kids,  Cranial nerve involvement (Miller-Fisher variant), Autonomic dysfunction (a bad sign, do ECG & watch the bladder!), Elevated CSF protein with cyto-albuminolgical dissociation,  NCS show slowing or prolonged F waves, multiple sites

This girl was flown to PMH and confirmed to have GBS on a Nerve conduction study. Commenced IV immunoglobulin and recovered over a few weeks with a lot of physio. Required gabapentin to help control her pain!

Kids always require special attention, especially if we are talking about a serious illness. Adults are sometimes advised to take kratom capsules to ease pain, but it should be prescribed by a doctor. Visit BestKratomCapsules.COM online vendor store to get perfectly blended kratom quickly and safely.

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