A Toddler Refuses to Walk

Abstract

A 15-month-old white female was initially seen by her primary care physician with abnormal gait and fussiness of 5 days' duration. She had gradually stopped walking over the previous 3 days.Initial laboratory examination in the primary care physician's office included a white blood cell count of 10 600/mm 3 , hemoglobin 10.8 g/dL, hematocrit 32.2%, and platelets of 426 000/mm 3 . Electrolytes were normal and the C-reactive protein (CRP) was mildly elevated at 1.6 mg/dL (normal 0-0.5 mg/dL). She was referred to our neurology service and admitted for diagnostic evaluation and management.She had been walking for 3 to 4 months, but now refused to stand or ambulate on her own. When made to stand, her legs would tremble and she would not take any steps. Her mother thought she was primarily favoring her left lower extremity. She cried and had a head lag when being pulled to a sitting or standing position but was comfortable on her parent's lap. The parents thought that she was more comfortable when her back was supported. Two days prior to admission she was unable to sit without support. She had a decreased appetite and decreased urine output along with a 3-day history of constipation. She had no vomiting. Her sleep patterns had changed as well, with frequent waking in the night, worsening over 5 days. The patient had been afebrile and had no history of trauma. She received an influenza vaccine, including H-1, and her 15-month immunizations 16 days earlier.Her most recent viral illness was 5 months prior to admission. Her growth and development were normal. She had a past medical history of eczema, which was being treated with hydrocortisone cream, and an allergy to peanuts manifesting with urticaria (type 1 cutaneous anaphylaxis). She had a 4-year-old brother in preschool who was not ill and she spent weekdays at a babysitter's house with 5 other children who were healthy.On physical examination, her temperature was 99.1°F, pulse 132 beats/min, respirations 24 breaths/ min, and blood pressure 116/61 mm Hg. She was fussy and appeared tired but was in no acute distress. HEENT (head, eyes, ears, nose, and throat) examination showed no decrease in the range of motion of her neck. Her oral cavity and pharynx were normal and there was no significant adenopathy. There was no bone or joint pain and no rashes. On neurologic examination, she was irritable, but alert and responsive for her age. Cranial nerves were intact. There was a head lag. She was unable to maintain posture and stand but could sit with support. However, muscle strength was judged to be 5+ in the upper and lower extremities. Reflexes were brisk and she had negative Brudzinski and Kernig signs. The remainder of the physical examination was normal.Additional laboratory evaluation included an erythrocyte sedimentation rate (ESR) of 65 mm/h (normal 0-20 mm/h) and CRP of 20 units (normal 0-8.2 units). Plain radiographs were negative for fractures; hip ultrasound was negative and a magnetic resonance imaging (MRI) of the brain, spine, and lower extremities was negat...

Espondilodiscitis en pediatría

“…La mayoría de los pacientes son menores de 5 años, sin prevalencia de género, y el área más comúnmente afectada es la región comprendida por L5-S1, seguida de L4-L5. Hallazgos clínicos, radiológicos y microbiológicos sugieren que son pocos los casos de etiología infecciosa en niños (5), sin embargo, algunos autores discuten la posibilidad de que su etiología sea infecciosa a pesar de los hallazgos de cultivos estériles (6). Existe la hipótesis de que estos se explicarían por el arribo de bacteriemias transitorias a la placa vertebral que se diseminan a través del disco intervertebral hasta la placa vertebral opuesta.…”

“…En cuanto a la fisiopatología, esta es diferente en niños y en adultos, ya que los niños tienen una rica vascularización intra-ósea anastomótica en la placa terminal del cartílago hialino, con arteriolas que penetran en el anillo fibroso, lo que aumenta la probabilidad de émbolos sépticos que producen microinfartos. A pesar de tratarse de una enfermedad auto-limitada y poco común, el reto de los clínicos se encuentra en tener en cuenta esta entidad entre los diagnósticos diferenciales, con el fin de realizar un diagnóstico y tratamiento oportunos (5).…”