Fever, Neck Stiffness, and Leg Pain in a 6-year-old Boy.

1. Maria S. Rueda, MD*,† 2. John T. Kulesa, MD*,‡ 3. Craig Sable, MD§ 4. Paul Manicone, MD‡ 1. *Department of Pediatrics 2. †Division of Infectious Diseases 3. ‡Division of Hospitalist Medicine 4. §Division of Cardiology, Children’s National Hospital, Washington, DC A 6-year-old boy with bicuspid aortic valve, coarctation of the aorta repaired in infancy, and atrial septal defect (ASD), status post device closure 6 months ago, is admitted to the general pediatric inpatient service. Three days ago he developed bilateral diffuse leg pain, persistent fever, and decreased oral intake. On the day of presentation he awoke with headache, neck stiffness, back pain, and pain on weight bearing. On review of his medical records, an echocardiogram immediately after cardiac catheterization and device closure showed a trivial residual atrial-level shunt. Angiography revealed no residual coarctation or discrete stenosis. He was seen for a dental cleaning 5 months before presentation and received amoxicillin prophylaxis. His parents report no recent travel or known tick exposure, although he does have several excoriated mosquito bites. At a local emergency department the patient refuses to bend his neck, denies photophobia, and is “sluggish and wobbly” on standing. Laboratory evaluation reveals a normal complete blood cell count, creatine kinase level, and basic metabolic panel. Urinalysis reveals 1+ protein, 1+ blood, and granular casts. Chest radiography shows no focal consolidation. Blood cultures are obtained, and ceftriaxone and vancomycin are administered. Given his cardiac history, he is transferred to a pediatric tertiary care center for further management. On admission, his vital signs are notable for fever (temperature, 103.1°F [39.5°C] axillary), tachycardia (pulse, 118 beats/min), and normal blood pressure (103/54 mm Hg). Physical examination demonstrates tenderness along the lumbar vertebrae and left midshaft femur, spasm of the cervical paraspinal muscles, negative Kernig and Brudzinski signs, antalgic gait, and a grade III/VI crescendo-decrescendo systolic murmur at the right upper sternal border. His lungs are clear. He has no hepatosplenomegaly. Evaluation of cerebrospinal fluid (CSF) reveals mild pleocytosis, with a white blood cell count of 13/μL (0.013 × 109/L) (90% neutrophils; reference range, …