Author: Richard Oravec, MD
Co Author #1: Nicole M. Protzman, MS
Co Author #2: Fidel D. Bautista, MD
Editor: Yaowen Hu, MD, MBA
Senior Editor: Mandeep Ghuman, MD
Left Ankle Pain, Sore throat, Fever
A 9 year-old female softball athlete presented to her pediatrician with left ankle pain 2 days after she developed an isolated, persistent sore throat. She noticed left ankle pain and bruising after a softball game but did not recall any injury. After noticing left ankle pain, she developed a fever with a maximum temperature of 104.0 degrees Fahrenheit (F), orally. Mild ankle effusion was noted on initial physical exam but no aspiration was done. She was prophylactically started on Amoxicillin for suspected Lyme disease and her sore throat was initially attributed to viral etiology.
Her initial outpatient CBC and x-ray were normal, but the Lyme titers and MRI were pending. The patient's ankle pain progressively worsened and she could not bear any weight. Her fever increased to 104.5 degrees F and she did not respond to medication. The patient complained of persistent chills, decreased appetite, fever, severe pain, fatigue, and poor urine output. There was night pain and severe pain during the day as well. She finally presented to the emergency room after 5 days of symptoms.
Height: 158 centimeters
Weight: 34 kilograms
Blood Pressure: 109/63 mmHg
Pulse: 120 beats per minute
Respirations: 24 breaths per minute
Oral Temperature: 101.0 degrees F
Oxygen Saturation: 97%
On physical examination, the patient was in distress, complaining, and moving in pain. She had dry mucous membranes, pharyngeal erythema, and and pharyngeal edema. The right ankle demonstrated swelling, erythema, warmth, diffuse tenderness, and limited range of motion because of pain. There was a large ankle effusion on exam. Ecchymosis was noted on the medial ankle. Her sensation and her skin were intact.
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