Fever and Limp in a 3-Year-Old Girl

Setshedi Makwinja, MD; Ben Numpang, MD; Benjamin R. Aubey, MD, MPH


October 28, 2015

The patient in this case was started on empiric intravenous antibiotic therapy, initially on ceftriaxone 75 mg/kg/day. Ultrasonography obtained shortly after admission was read as a "negative study of the upper abdomen, perirenal and perivertebral lower thoracic lumbar area." Following consultation with the infectious disease service, the antibiotic regimen was changed to cefepime to provide better broad-spectrum coverage.

A review of the MRI findings with the interventional radiology department led to the decision that an invasive drainage procedure for a relatively small collection would not be immediately warranted, and a "wait-and-see" approach to determine the response to the intravenous antibiotics would be the best course of action. After 3 days of intravenous antibiotic therapy, the child's fever subsided, and she was noted to be moving around without limping and with no residual tenderness on examination. In fact, her mother described her as "back to her old self." A consultation with the neurology service found no neurologic deficits, and the initial limp was attributed to pain. A repeat CRP level was obtained, with a result of 34.5 mg/L. The final results of the blood and urine cultures, as well as a purified protein derivative, were all negative.

Because the child was doing well clinically (running and jumping up and down) and had a compliant parent, the patient was discharged on hospital Day 5 with a combination antibiotic regimen of rifampin and amoxicillin/clavulanic acid for 4 weeks, along with appropriate outpatient follow-up with her primary pediatrician and an infectious disease specialist.

Repeat MRI scans performed at 1 month and again at 3 months after discharge demonstrated complete resolution of the collections, except for a residual "abnormal signal intensity in the right pedicle of L3," which persisted with no identifiable clinical impact; the patient was noted to have complete resolution of her symptoms. The use of IV antibiotics as the sole modality of therapy in this case was unusual for the management of a psoas abscess.


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