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
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!)
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
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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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Great case! With regard to polio I think it is at least important to think about if you live in an area with a high population of people who do not participate in vaccination. The chance of polio is slim to none, but this sort of case is exactly what patient zero in a first world outbreak will look like!
Cheers,
Dr. J
Thanks Dr J. Yes, polio – you have to keep it in the back of your mind. Rare, more common nowadays would be a post-viral transverse myelitis.
Casey