Hurtn’ to stand: Discitis

Case presentation

An 18-month-old female presents with 1 to 2 weeks of fussiness and not wanting to ambulate. She has not had any fevers, vomiting, or diarrhea. There is no report of trauma. About 2 weeks prior, she had a cough, congestion, and low-grade fever (100.4 degrees Fahrenheit) that resolved after a few days. She has been healthy since then.

Her primary care physician evaluated the child 1 day after her symptoms began. At that time, the child was complaining of what was thought to be left leg pain (the mother stated that the child cried when attempting to ambulate and did not seem to want to bear weight on the left leg). Plain radiographs of the pelvis (including anterior-posterior [AP] and frog leg views), the left femur, and left tibia-fibula were obtained and were unremarkable. Since that time, the child has refused to ambulate and does not want to bear weight on either leg. Her primary care provider obtained a bilateral hip ultrasound (US), which was unremarkable.

Her physical examination shows a child in no distress. Her temperature is 98 degrees Fahrenheit, heart rate is 101 beats per minute, respiratory rate is 22 breaths per minute, and blood pressure is 90/60 mm Hg. She has an unremarkable examination, including her neurologic examination, which demonstrates no weakness or obvious lack of sensation. When attempting to ambulate, she refuses to do so and in fact cries when standing upright. She does not have any obvious findings on her extremities and range of motion maneuvers at her hip, knees, and ankles are normal. You note that the child prefers to lie down and, when she sits up, appears to be in discomfort.

Imaging considerations

Gait disturbances in the pediatric patient have a lengthy differential diagnosis to consider. History and physical examination should guide further laboratory and radiographic evaluation.