Any Diff Dx ideas?

[Alley Cat]

Just started Peds this week and this kid comes in today that has me thrown for a loop. So I'm just looking for a few good differentials. Here's the scoop: 12 y/o caucasian-spanish male c/o weakness, fatigue, myalgias, night fevers w/ chills and paresthesia to both legs with occasional burning sensation. States that he cannot walk or run far due to muscle weakness. Mother states that has been going on for 3-4 months and was accused of malingering in the Urgent Care last week when had a febrile episode. PE: normal gait, somewhat stooped (slouching) appearance. Skin: no rashes, plaques or eccezematous lesions. HEENT: unremarkable. Chest/lungs unremarkable. No organomegaly or ttp. Extremities have FROM but bilateral weakness, no ttp. Serum IgE is marked elevated >4500 with some proteinuria. All other labs are otherwise unremarkable.

Kinda gets the brain to tickin'. Any ideas are appreciated.

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[Tired]

Neurological problems require a neurological workup. Where's the imaging?

 

[Alley Cat]

They just presented to clinic today, so no imaging results. I'm gearing more towards the fever and elevated IgE until more results are in.

 

[Hard24Get]

Just started Peds this week and this kid comes in today that has me thrown for a loop. So I'm just looking for a few good differentials. Here's the scoop: 12 y/o caucasian-spanish male c/o weakness, fatigue, myalgias, night fevers w/ chills and paresthesia to both legs with occasional burning sensation. States that he cannot walk or run far due to muscle weakness. Mother states that has been going on for 3-4 months and was accused of malingering in the Urgent Care last week when had a febrile episode. PE: normal gait, somewhat stooped (slouching) appearance. Skin: no rashes, plaques or eccezematous lesions. HEENT: unremarkable. Chest/lungs unremarkable. No organomegaly or ttp. Extremities have FROM but bilateral weakness, no ttp. Serum IgE is marked elevated >4500 with some proteinuria. All other labs are otherwise unremarkable.

Kinda gets the brain to tickin'. Any ideas are appreciated.

Where is the neuro exam? How weak was he (on a 5pt scale)? Was he numb on challenge (temp, proprioception, etc - is that ttp?)? What were is reflexes? What were he vitals? Any tenderness over the spine? Does he have back pain regularly or upon straightening up? Did the sx have a sudden or insidious onset? Any trips out of the country? What is the medical history?

Interesting case, would like to hear more before learning of the imaging. Probably the worst thing it could be would be some type of epidural abscess, maybe even parasitic given the IgE. The IgE may also indicate hyperIgE syndrome, which would predispose to bacterial abscesses. Also in the differential I would think would be masses like lymphoma or NB. You should be able to localize the lesion on exam, however.

 

[Adcadet]

Yeah, need a good neuro exam. The only thing I can think of to tie these vague symptoms, unrevealing exam, and almost no labs together wold be a paraneoplastic neurologic syndromes, and maybe some cord pathology. I'm guessing the rest of the CBC was normal...? Give us a neuro exam!

 

[chameleonknight]

Not sure if this helps, but here's a good article on muscle weakness.

http://www.aafp.org/afp/20050401/1327.html

You could generate some pretty long DDx from those symptoms.

 

[pillowhead]

Just started Peds this week and this kid comes in today that has me thrown for a loop. So I'm just looking for a few good differentials. Here's the scoop: 12 y/o caucasian-spanish male c/o weakness, fatigue, myalgias, night fevers w/ chills and paresthesia to both legs with occasional burning sensation. States that he cannot walk or run far due to muscle weakness. Mother states that has been going on for 3-4 months and was accused of malingering in the Urgent Care last week when had a febrile episode. PE: normal gait, somewhat stooped (slouching) appearance. Skin: no rashes, plaques or eccezematous lesions. HEENT: unremarkable. Chest/lungs unremarkable. No organomegaly or ttp. Extremities have FROM but bilateral weakness, no ttp. Serum IgE is marked elevated >4500 with some proteinuria. All other labs are otherwise unremarkable.

Kinda gets the brain to tickin'. Any ideas are appreciated.

I think it's unlikely but what about some kind of muscular dystrophy? Not new-onset Duchenne's in a 12 y/o but what about Beckers? He's about the age it presents. Bilateral leg weakness, esp in a young male would definitely make me at least check at CPK (CK?) level.

 

[Hard24Get]

I think it's unlikely but what about some kind of muscular dystrophy? Not new-onset Duchenne's in a 12 y/o but what about Beckers? He's about the age it presents. Bilateral leg weakness, esp in a young male would definitely make me at least check at CPK (CK?) level.

But Becker's muscular dystrophy shouldn't have a sensory component, should it? How about charcot marie tooth in that category?

We really need the neuro exam and maybe even an EMG to differentiate between muscular and neurologic origins. Which reminds me, another differential could be CDIP...

 

[Tired]

The ddx the last couple posters here are focusing mainly on the bilateral lower extremity weakness, which may be a bad choice, since we don't really have a good objective neuro exam.

In my mind, the night fevers are a little significant, since the BLE weakness could simply be a symptomatic response to a systemic illness, rather than a "true" symptom of the disease. Off the top of my head, I was thinking more along the lines lymphoma, leukemia, other underlying malignancy, malaria, parasitemia. The age group makes it less likely, but this kid may have a big tumor sitting on his falx (explains both weakness and night fevers).

I still think it's questionable to chase the IgE unless there is some other sign or symptom of immunodeficiency or something funky like Churg-Strauss.

Also, are the night fevers actually documented fevers, or is this how the mother describes night sweats?

 

[pillowhead]

But Becker's muscular dystrophy shouldn't have a sensory component, should it? How about charcot marie tooth in that category?

We really need the neuro exam and maybe even an EMG to differentiate between muscular and neurologic origins. Which reminds me, another differential could be CDIP...

I don't really think it is MD, but it's the kind of thing that can be ruled out fairly easy by a simple lab test. I agree that the problem sounds more like a systemic one but with the information given, I'd still want to rule it out.

 

[Hard24Get]

Hey Alley Cat, when you post a case, you're supposed to give follow-up so all can learn from it....


What differential did your team come up with and how did they test them? What was the result?

Thanks!

 

[SaraMac13]

I agree- we need a good neuro exam to localize the lesion. I would definitely image the spine---his "stooping appearance" could be a sign of vertebral compression from etiher a tumor or abscess (which would also explain fever/night sweats). Could be Pott's disease (TB in the spine), but probably not likely unless there's a lot of TB in your area (there is in mine)

 

[ericdamiansean]

I'm thinking along the line of an infectious cause, probably a parasite. Do a FOBT, stool FEME, blood smear (thick and thin)

there's a lot of TB in your area (there is in mine)

Since when did the US get so many TB cases? Immigration?

 

[a_ditchdoc]

I am going to place my bets on some type of parasitic illness. Trichinosis would be at the top of my D/D, because of the elevated IgE and proteinuria, probably secondary to muscle breakdown. Cysticercosis would be on my list, although the presentation is not typical. From there my list would inlcude the myotonic dystrophies.

Let us know what you find out....

 

[Tired]

Since when did the US get so many TB cases? Immigration?

"A lot" is pretty relative. In reference to other areas, the U.S. has basically no Tb. But yes, there has been a rise in many areas of the U.S. due primarily to immigration.

 

[ericdamiansean]

"A lot" is pretty relative. In reference to other areas, the U.S. has basically no Tb. But yes, there has been a rise in many areas of the U.S. due primarily to immigration.

Back here, we pretty much eradicated it with the immunization program but it came back from Indonesian immigrant workers

 

[Adcadet]

Back here, we pretty much eradicated it with the immunization program but it came back from Indonesian immigrant workers

Where are you, Europe? And are you sure it was an immunization program and not testing/isolation/treatment? Last I checked BCG wasn't that effective.

 

[ericdamiansean]

Where are you, Europe? And are you sure it was an immunization program and not testing/isolation/treatment? Last I checked BCG wasn't that effective.

Asia. It's part of the immunization program here, given at birth, single dose. I did a quick review on a few papers, it does offer a more than 50% reduction from morbidity. Not bad when your country's plagued with tb. I've seen it being given and personally, the problem with effectiveness usually do not come from the vaccine itself but from how it was given, stored etc. So, yes, it is not THAT effective but it still is

 

[Adcadet]

I'm talking incidence, you're talking morbidity. But OK.

I still suspect that BCG had less to do with the near-eradication of TB in Asia than isolation/contact tracing/treatment. I love vaccines, but from what I recall from my ID epi class (~5 years ago now) the vaccine had little to do with control of TB in Europe and the US. In fact, I remember TB-active meds really only coming on the scene after the incidence was falling. But maybe things are different in whatever part of the world your in, or maybe my memory from 5+ years ago is a bit fuzzy. But I think we can both agree to place a PPD with controls if the kid has any risk factors (or things just really don't add up) and he didn't get the BCG vaccine.

 

[SaraMac13]

Hi - yeah, I guess its all relative. I'm at LA County where we see a lot of immigrants from Mexico, Central America, and Asia, so in comparison to other places in the US we see "a lot" of TB, but probably not compared to overseas. All I know is that practically everyone with a chronic cough immediately gets a mask, a PPD, and is isolated until they get ruled out. Let us know what the actual dx is when you get a chance

 

[Alley Cat]

Okay guys, sorry to leave you hanging (internet difficulties), but got some more of the goods. So the 12 y/o kid's repeat IgE levels are the same which r/o lab error (~5000), CBC unremarkable, CK w/in normal limits, RAST testing showed he's highly allergic to several strains of Asperillogis sp. (Aspergillus fumigatus, Aspergillus flavus, Aspergillus niger. Aspergillus clavatus, Aspergillus glaucus group, Aspergillus nidulans, Aspergillus oryzae, Aspergillus terreus to name a few). His O/P also came back with trophozoites and cysts from 2 different species (can't remember the names) but both not treatable (according to Pediatrician) becuase they are both considered opprotunistic/normal flora. Sorry guys no neuro exam/studies were done - BUT it was also revealed the kid may be harboring some depression (poss somatic complaints) because some other kids were making fun of him at his school rumoring he was gay, which may explain some of the vague GI symptoms, and possible weakness. However, he still has some nighttime fevers and a high IgE level. The Pediatrician is now going to refer him to an Infectious Disease Specialitist to determine some sort of immunosuppression. So, thanks for being so patient and if I hear of anything new, I'll keep everyone posted. I'll be sure to inform the doc of all the great differentials that everyone posted.

 

[ericdamiansean]

His O/P also came back with trophozoites and cysts from 2 different species (can't remember the names) but both not treatable (according to Pediatrician) becuase they are both considered opprotunistic/normal flora.

I don't have (I think) trophozoites or cysts ..I really doubt that's normal/opportunistic flora..so, coupled with the IgE levels, it should be a parasitic infection

 

[Alley Cat]

The two positive parasite results are Endolimax nana trophozoites/cysts, and Entamoeba coli trophozoites/cyst, but not particularly specific for Cryptosporidium.