SHARE @ Advocate Health - Midwest - Scientific Day: A Limp to Diagnosis: Unraveling the Mystery of an Abnormal Pediatric Gait
 

Affiliations

Advocate Children's Hospital, Advocate Christ Medical Center

Abstract

Introduction/Background:

Semi-acute progressive lower extremity musculoskeletal pain has a broad differential diagnosis including infections (e.g., osteomyelitis), MSK (e.g., slipped capital femoral epiphysis [SCFE]), and oncological (e.g., leukemia and bone tumors) etiologies. In the setting of subtle neurological findings, it is important to consider spinal lesions such as a primary tumor, congenital anomaly, or infection.

Description:

A 6-year-old male with a history of chronic lower leg complaints presented with one month of right proximal tibia pain and a new limp. His pain increased during the day and often woke him from sleep. He also reported decreased activity, anorexia, weight loss and intermittent night sweats. The pain was treated with acetaminophen and ibuprofen with minimal relief. He noted upper respiratory symptoms and fever with pain onset, but none at admission. He had no joint swelling or history of trauma, and the review of systems was otherwise negative. Initially he was felt to be experiencing growing pains, however given the progression of pain and systemic symptoms, he was admitted to the hospital for further work up. On exam, patient was non-toxic appearing. His right lower extremity had pain to palpation over the proximal outer tibia, without erythema, swelling, or limitations in range of motion. He had pain to palpation over his lower lumbosacral spine and paraspinal musculature with radiation to the right tibial region. Neurological exam revealed a right sided limp with ambulation, 4/5 strength in right lower extremity, normal reflexes and no focal deficits. Labs including inflammatory markers, creatinine kinase, and tumor lysis markers were unremarkable. X-rays of hip, femur and tibia revealed a slight displacement of the right femoral head that was clinically insignificant. He underwent an MRI spine that demonstrated an extramedullary intradural lesion at the L4 level.

Discussion:

The patient’s MRI finding was consistent with an epidermoid inclusion cyst, likely a rare sequela of a lumbar puncture he had received at 4 weeks of age during a septic workup. Epidermoid cysts can result from iatrogenic implantation of ectodermal tissue during procedures like lumbar punctures. These cysts can present later in life with neurological deficits, including pain, motor weakness, or sphincter dysfunction. This case underscores the importance of avoiding diagnostic anchoring bias, as maintaining a “working differential” can be crucial to uncovering rare conditions and allow for timely imaging and appropriate therapies.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

Full Text of Presentation

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Document Type

Poster


 

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May 21st, 11:41 AM May 21st, 1:15 PM

A Limp to Diagnosis: Unraveling the Mystery of an Abnormal Pediatric Gait

Introduction/Background:

Semi-acute progressive lower extremity musculoskeletal pain has a broad differential diagnosis including infections (e.g., osteomyelitis), MSK (e.g., slipped capital femoral epiphysis [SCFE]), and oncological (e.g., leukemia and bone tumors) etiologies. In the setting of subtle neurological findings, it is important to consider spinal lesions such as a primary tumor, congenital anomaly, or infection.

Description:

A 6-year-old male with a history of chronic lower leg complaints presented with one month of right proximal tibia pain and a new limp. His pain increased during the day and often woke him from sleep. He also reported decreased activity, anorexia, weight loss and intermittent night sweats. The pain was treated with acetaminophen and ibuprofen with minimal relief. He noted upper respiratory symptoms and fever with pain onset, but none at admission. He had no joint swelling or history of trauma, and the review of systems was otherwise negative. Initially he was felt to be experiencing growing pains, however given the progression of pain and systemic symptoms, he was admitted to the hospital for further work up. On exam, patient was non-toxic appearing. His right lower extremity had pain to palpation over the proximal outer tibia, without erythema, swelling, or limitations in range of motion. He had pain to palpation over his lower lumbosacral spine and paraspinal musculature with radiation to the right tibial region. Neurological exam revealed a right sided limp with ambulation, 4/5 strength in right lower extremity, normal reflexes and no focal deficits. Labs including inflammatory markers, creatinine kinase, and tumor lysis markers were unremarkable. X-rays of hip, femur and tibia revealed a slight displacement of the right femoral head that was clinically insignificant. He underwent an MRI spine that demonstrated an extramedullary intradural lesion at the L4 level.

Discussion:

The patient’s MRI finding was consistent with an epidermoid inclusion cyst, likely a rare sequela of a lumbar puncture he had received at 4 weeks of age during a septic workup. Epidermoid cysts can result from iatrogenic implantation of ectodermal tissue during procedures like lumbar punctures. These cysts can present later in life with neurological deficits, including pain, motor weakness, or sphincter dysfunction. This case underscores the importance of avoiding diagnostic anchoring bias, as maintaining a “working differential” can be crucial to uncovering rare conditions and allow for timely imaging and appropriate therapies.

 

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