Interactive Quiz: Heel Pain and Diarrhea in a Young Boy
Welcome to Gastroenterology Consultant's latest interactive diagnostic quiz. Over the next few pages, we'll present a case and ask you to make the diagnosis and treat the patient. Along the way, we'll provide details about the case, and at the end, we'll share the patient's outcome.
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First, let’s meet the patient …
A previously healthy 7-year-old boy presented after 3 weeks of recurrent fevers, left lower-extremity pain, and mild diarrhea.
All symptoms had been present concurrently over 3- to 4-day intervals and would subside for a few days before beginning again. Fevers usually occurred in the afternoon, along with diarrhea 1 to 2 times a day. The diarrhea was watery, with no blood or mucus, and was associated with abdominal pain and discomfort. Left lower-extremity pain was localized to the heel and ankle, with point tenderness at the medial calcaneus.
At admission, results of a complete blood cell count demonstrated no leukocytosis, microcytic anemia (hemoglobin, 9.7 g/dL; mean corpuscular volume, 67.1 µm3), and a slightly elevated platelet count of 728 × 103/µL. Blood culture results were negative for gram-negative bacteria. The C-reactive protein (CRP) level was 13.6 mg/L, and the erythrocyte sedimentation rate was 66 mm/h. Uric acid and lactate dehydrogenase levels were within normal limits. Findings of a comprehensive metabolic panel (CMP) revealed a slightly low albumin level of 3.2 g/dL.
Are you correct? >>
Answer: Intravenous clindamycin
The patient was started on intravenous (IV) clindamycin due to concern for bacterial calcaneal osteomyelitis.
The results of magnetic resonance imaging (MRI) demonstrated a focus of inflammation in the left calcaneus but were not definitive for osteomyelitis. After 72 hours of antibiotic therapy, the patient had minimal to no improvement, and the infectious disease service was consulted. Per their recommendation, the patient was switched to IV ceftaroline to broaden coverage.
Although the boy’s heel pain began to slowly improve, his fevers persisted. After 36 hours of ceftaroline, his CRP level remained elevated at 12 mg/L. At this time, the patient abruptly had 10 episodes of diarrhea within 24 hours, with fecal incontinence, spasmodic cramping, and intermittent tenderness in the right lower quadrant.
Clostridium difficile test results were negative. The gastroenterology service was then consulted due to increasing concern that this patient’s illness was not infectious.
Are you correct? >>
Answer: Computed tomography
The gastroenterology service obtained a computed tomography (CT) scan of the chest, abdomen, and pelvis, the results of which demonstrated mural enhancement of the right colon and distal small bowel. A repeated CMP demonstrated a new hypoproteinemia of 5.9 g/dL, an albumin level of 2.8 g/dL, and a CRP level of 14.9 mg/L.
The patient subsequently underwent bowel cleanout, esophagogastroduodenoscopy, and colonoscopy, the results of which revealed the following: scattered white plaques and superficial ulcers in the distal portion of the esophagus; 2 small superficial ulcers on the pylorus; mild erythema and ulcers on the duodenal bulb; and scattered exudates, erythema, and superficial ulcers in the terminal ileum, cecum, and right colon.
Are you correct? >>
Answer: Crohn disease
The biopsy revealed mild to severe esophagitis, gastritis, and duodenitis, as well as findings consistent with Crohn ileocolitis. Antibiotics were then discontinued, and the patient received a diagnosis of Crohn disease (CD). The patient was treated with 20 mg of IV methylprednisolone and was transitioned to an oral prednisolone taper. He received a transfusion of iron sucrose for his microcytic anemia, which was thought to be anemia of chronic disease.
At the end of his hospital course, the patient was able to ambulate without assistance, and his presenting symptoms had diminished. Prior to discharge, he was placed on azathioprine, 50 mg once daily, along with ranitidine, iron, and vitamin D.
At his first gastroenterology follow-up visit, the patient reported continued joint pain that had localized to his knees and that worsened with activity.
Are you correct? >>
Answer: Prolong the taper duration
The patient’s prednisolone dose was increased and his taper duration prolonged. His symptoms improved, and he was weaned from oral corticosteroids.
Although primarily a disease of the intestines, complications and associated symptoms of IBD can occur outside of the intestines. Studies have shown that approximately 29% of pediatric IBD patients will develop at least 1 extraintestinal manifestation (EIM) within 15 years of diagnosis.
Of particular relevance to this patient’s case, studies have shown that approximately 6% of patients with IBD have an EIM prior to diagnosis. The most common EIMs are joint pain and aphthous stomatitis. Sometimes the EIM may even be the most prominent symptom.
Answer: Enteropathic arthritis
It was determined that the patient’s presenting symptom of lower-extremity pain was most likely due to enteropathic arthritis in a type 1 peripheral pattern, given that his arthritis was asymmetric, was nondeforming, occurred in the ankle and knees, and mirrored gut activity.
It is possible that the patient also has associated enthesitis, which involves the Achilles and plantar fascia insertions on the calcaneus—precisely where our patient’s pain was the worst. Furthermore, enthesitis is known to cause focal inflammation and marrow edema with enhancement on T1-weighted imaging, which adequately explains his nonspecific MRI findings.
To read the full case report, see:
Mueller G, Ohienmhen B. Crohn disease. Consultant. 2018;58(9):252-255. https://www.consultant360.com/article/gastroenterology/pediatric-gastroenterology/crohn-disease.