A 16 yo F presents with 21 days of fever, worsening fatigue, and wrist pain.
Physical Exam
Exam notable for:
- Erythematous rash on cheeks that crosses nasal bridge
- Redness of hard palate
- Cervical lymphadenopathy
- Swelling of ankles
- BP is 133/95
Diagnostic Workup
- HEADSS assessment unrevealing
- Lost weight in the past few months
- No concern for infectious exposure history
- Labs: WBC 3.2, Hgb 10.4 (MCV96), Plt 140, CRP 1.7, ESR 94, uric acid 5.8, peripheral smear with normocytic anemia but no blasts, EBV IgG positive but IgM negative
Next Steps
- Mom recalls that patient’s grandmother has lupus
- Consult nephrology about her BP, and they suggest getting a UA
- Additional labs show C3 of 21 and undetectable C4
- UA shows 3+ blood and 3+ protein
- You then get an ANA that is positive at 1:1280, concerning for lupus
- Referral to rheumatology – she is seen in pediatric rheumatology the following week
Diagnosis & Treatment
- Kidney biopsy the following week shows class V lupus nephritis
- She is started on steroids and mycophenolate
Clinical Pearl
Make sure to ask review of systems questions not only for the period of fever, but also for the weeks-months preceding onset of fever. This can provide many clues!
A 9 yo F with systemic JIA who is managed with steroids and tocilizumab presents to clinic with 4 days of fever.
Physical Exam
Exam notable for:
- Fever of 39°C
- HR 120
- Flow murmur at lower sternal border
- Some shoddy cervical lymphadenopathy
Diagnostic Workup
Initial
You have a lab in your office and decide to run the following:
3 Days Later
- Patient presents with persistent fevers, fatigue, and new shortness of breath.
- The murmur you heard before is now louder, and you note new red nodules on the bilateral palms.
Next Steps
- You direct family to the ER.
- Echocardiogram confirms your suspicion for endocarditis. Blood culture grows staph aureus and patient is initiated on IV antibiotics.
Clinical Pearl
Tocilizumab inhibits IL-6, which helps promote production of CRP, so this patient’s normal CRP was actually inappropriately low.