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Case Study

A 3-year-old boy with irritability, digital erythema, and leg pain

A 3-year-old boy is brought to your office by his parents, who state that the child refuses to play and prefers to lie on his bed. His parents note that about a month ago, he seemed to withdraw and become cranky. Recently, he has experienced night sweats. On those nights the child has felt warm, but his parents did not take his temperature. The child has had no other symptoms, such as a runny nose or cough, and has not lost weight.

History reveals that the patient had recurring ear infections this past winter, which were treated with oral antibiotics. His growth and development have been normal; he is in the 90th percentile for weight and height. The child’s immunizations are up to date, and he is on no medications.

During physical examination, the boy is uncooperative and crying. He refuses to walk or stand and says that his legs “hurt.” He is afebrile, has a heart rate of 130 per minute and respirations of 16 per minute. He is sweating, and his nose, fingers, and toes are erythematous; the skin on his fingers and toes is peeling. The oral pharynx and abdomen appear normal upon examination; his lungs are clear. He does not have point tenderness in his legs, and he has full range of motion in knees and hips. His ankles are not edematous. Results of the neurologic examination are normal; there is no muscular atrophy. Other findings are unremarkable.

Three months ago, the child, his parents, and his 6-year-old sister moved into a freshly painted house. The parents report that their daughter appears healthy and is doing well in first grade. Both parents are school teachers in good health. The family has no pets and has not traveled within the past year. Until recently, the boy has enjoyed most social activities with his family.

(a) What should be included on the patient’s problem list?


(b) What is the differential diagnosis for this patient?


(c) What tests would you recommend to confirm or rule out a diagnosis?


(d) What treatment and follow-up would you recommend?


Answers can be found on pages 21–2.

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