422 Emergency Medicine
not one specifically associated with treatment of pneumonia and acute
chest syndrome.
374.The answer is d.(Fleischer and Ludwig, p 1694.)This is a case of
toxic synovitis, also called transient synovitis, of the hip.Despite its
name, this is a benign and self-limiting condition that typically responds to
rest and NSAIDs. It is thought to be a postinfectious inflammatory
process, though the true cause is unknown. The course is usually from
several days to a couple of weeks. Though fever is not a typical part of most
patients with toxic synovitis, it can be present and low grade or could
potentially be unrelated (note this child has concurrent upper respiratory
infection [URI] symptoms). It is most important to distinguish this condi-
tion from a septic arthritis. The main differences are that the joint can often
be gently maneuvered in toxic synovitis whereas in true septic joints even
the smallest amount of joint motion typically produces intense pain and
patients will strongly resist full range of motion.
If this was a septic joint, it would be important to (a)admit the child for
IV antibiotics, but probably more importantly to (b)consult orthopedics for
a probable trip to the operating room where the joint would be aspirated and
irrigated. This is not a case where a bone scan (c)would be indicated to rule
out osteomyelitis, especially in light of totally normal inflammatory markers.
Finally, although we often worry about occult, or Salter-Harris I, type frac-
tures (e), this patient has no history of trauma and no point tenderness and is
weight bearing at the time of discharge making this a very unlikely diagnosis.
375.The answer is e.(Fleischer and Ludwig, pp 1305-1311.)This is a patient
with Kawasaki disease (KD). This entity is defined by the following criteria:
fever lasting for a minimum of 5 days, plus four out of five of the follow-
ing: cervical lymphadenopathy of greater than 1.5 cm; dry, cracked lips
or other oral mucous membrane involvement (strawberry tongue); trun-
cal, nonvesicular rash; nonpurulent conjunctivitis; swollen or edematous
hands and feet.KD is a systemic inflammatory vasculitis of unknown etiol-
ogy. The characteristic constellation of symptoms, as this patient meets,
requires immediate action to prevent complications of the disease. Another
common finding, and one which many practitioners use to help in the diag-
nosis of “atypical” cases, is intense irritability of the child. The most serious
sequelae involve coronary artery aneurysms. These occur in approximately
20% to 25% of untreated patients. This number is reduced to around 4% to
5% if treatment occurs within the first 10 days of symptom onset. Additional