A Harry Potter fan

摘要

A 14-year-old white boy presented to his primary care physician (PCP) with a 3-day history of high fever (>102°F), 2 days of increasingly severe arthralgia, and a rash that began on the day of his outpatient visit. He also had lethargy, poor appetite, and increased sleeping for 3 days. There were no respiratory symptoms or abdominal complaints other than 1 episode of vomiting 1 day earlier. His arthralgia was sufficiently severe to cause difficulty in walking and pain with any movement of his left elbow. The elbow became swollen on the day of his exam. He was not sexually active. Past medical history and family history were essentially noncontributory. A physical exam in the PCP's office yielded the following: a temperature of 102°F, pulse rate of 104 beats/ min, respiratory rate of 26 breaths/min, and blood pressure equal to 126/84 mm Hg. He was ambulatory, appeared nontoxic, alert, and cooperative but was in obvious discomfort secondary to a headache and joint pain. There was no conjunctivitis or pharyngitis. Exam of the heart and lungs was normal. Examination of his joints revealed a small effusion in his left elbow but no obvious effusion in his knees and hips where he complained of limitation of movement without increasing pain. He had a maculopapular rash primarily on the extensor surfaces of his arms and legs that was partially blanching and did not involve the palms and soles. There were some small nodes palpated in the anterior cervical triangle and inguinal regions but no supraclavicular nor axillary adenopa-thy. The neurological exam was normal. Initial laboratory studies obtained by the PCP included a white blood cell count of 13 840/mm with 68% polymorphonuclear neutrophils, 2% bands, 27% lymphocytes, and 2% monocytes. The erythrocyte sedimentation rate was 47 mm/h, and C-reactive protein level was 31 mg/L (normal <8.4 mg/L). A urine sample contained 1+ protein but was otherwise normal. The PCP then proceeded to a telephone consultation with our infectious disease service.