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Clinical Case 17
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1

HK is a 5 year-old girl who has to the clinic for evaluation of fever, arthralgias, fatigue and rash. She developed a fever approximately 2 weeks ago and has had a daily fever to at least 38.5C., associated with malaise and an erythematous macular rash which seems to resolve when her fever is controlled. Her knees, elbows and back have been the most painful, but she has also complained of pain in her hands and feet. She has had minimal improvement with Ibuprofen and acetaminophen. She is home-schooled along with her 5 siblings and has had no known sick contacts. She has no past medical history. She has had all her childhood immunizations. When she was assessed in the emergency department 1 week ago, her parents were told this was ‘just the flu.’

On physical examination the patient has a temperature of 39.3C. and has a macular rash diffusely over her trunk. Her knees, elbows and hands are warm and moderately swollen but without obvious effusion. She has mild hepatomegaly and the tip of her spleen is palpable. The remainder of her physical exam is normal.

Lab: WBC 12.5 (with 75% neutrophils) Hct 30 MCV 68 Plt 600K Westergren ESR 60
Total Bilirubin 1.0 AST 42
Other labs are pending

Which of the following is the most likely diagnosis?
A)Acute viral hepatitis
B)Systemic lupus erythematosis
C)Mycoplasma pneumoniae sepsis
D)Juvenile rheumatoid arthritis
E)Septic arthritis







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