Multifocal Bone Pain, Fevers, And An Enhancing Clavicular Lesion In An 11-Year-Old Liberian Boy

1. John Scheuer, BA*\n2. Alice Lehman, MD*\n3. Cynthia Howard, MD†\n4. Emily Greengard, MD‡\n5. Alexander A. Boucher, MD‡\n\n\n \n\n1. *Department of Pediatrics,\n\n2. †Department of Pediatrics, Division of Global Pediatrics, and\n\n3. ‡Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Minnesota Medical School, Minneapolis, MN\n\nAn 11-year-old boy is transferred from a community emergency department to a university hospital with multifocal bone pain and fevers for 2 weeks. The pain sites include his clavicles, forearms, right leg, and chest, and he has been “crying all night” despite daily use of ice and ibuprofen. He also endorses difficulty walking, fatigue, and anorexia.\n\nOn physical examination he has a temperature of 100°F (37.8°C) and is tachycardic (heart rate, 118 beats/min) but normotensive. He appears ill and distressed. He has mild scleral icterus and nontender mild hepatomegaly. He has palpable tenderness over his reported pain sites. A 1 × 1-cm warm, soft mass is noted over the mid-shaft of his left clavicle. His laboratory results, shown in Table 1, demonstrate leukocytosis (white blood cell count, 17,700/μL [17.7×109/L]), microcytosis (mean corpuscular volume, 75 µm3 [75 fL]), and reticulocytosis (absolute reticulocyte count, 143×103/µL [143×109/L]), along with an elevated C-reactive protein level (106 mg/dL [1,060 mg/L]) and erythrocyte sedimentation rate (36 mm/h).\n\nView this table:\n\nTable 1. \nLaboratory Findings in the Patient and Normal Values\n\n\n\nThe patient is admitted to the hospital for further diagnosis and management with fluids, morphine, and empirical ceftriaxone and vancomycin. Blood cultures from admission are negative, but an interferon-gamma release assay is positive. Point-of-care ultrasonography shows a small area of echogenicity overlying the left clavicle. A chest radiograph demonstrates no nodules or opacities in the lungs and no apparent clavicular abnormality. Magnetic resonance imaging (MRI) of the left clavicle confirms the irregularity detected on ultrasonography, described as a 2.3 × 0.6 × 1.7-cm fluid collection anterior to the …