13. The Swing


'Stop it.' Jax said laughing as I was throwing little paper balls in his head. 'Otherwise, I'm never gonna finish.'
'You're already taking forever!' I complained.

We had decided to have breakfast together after our 28-hour shifts. I had already finished my paperwork and was waiting for Jax to finish his so we could go to our favorite diner.
'Well, feel free to help!' He threw one of my paper balls back at me.
'Fine.' I got up and sat beside him on the computer. 'What do you need?'
I started helping him for about 20 minutes until Natalie, Jax's intern, popped up at the door.
'Hey, Jackson!'
'Hi, Nat! How's everything?'
'It's going well. I was wondering if you could give me a hand on a case.'
'Sure.' He said and turned to me. ‘Can you wait a bit, Liz?’
I laughed. ‘Only if I can tag along.’
'Deal. Shoot, Nat.'
Natalie came in and sat on the free computer next to Jax. 
'I have a 5-year-old, Henry Scott. His mother brought him to the ER late last night for pain and swelling in the right elbow after a fall from the swing 2 days ago.’ Jax nodded for her to continue.
‘Ortho looked at it and ordered an x-ray. No fractures were seen and a bandage was made for the excoriation.’
‘Ok, so he wasn’t even admitted I’m guessing. So why do you need me?’
‘Well… the mother saw me in the hallway and asked to talk. She was worried because before they left, Henry started complaining of pain in his other elbow, which is now also swollen.’
Jax elevated his eyebrows. ‘That’s weird.’
‘I know. I think he has something else, but I still don’t know what. I could use some help.’ She offered a smile.
‘Right. What else do you know about him?’
‘He’s five and previously healthy. Never had any health issues besides common colds. Since yesterday he developed severe pain and swelling in both elbows, initially associated with trauma, but now questionable.’
‘How swollen?’ I asked. 
‘Pretty swollen.’ 
‘Let’s go see him.’ Jax said already getting up.

‘Hi, tough guy!’ Jax lifted up his fist and Henry bumped it smiling. ‘Hi, Mrs. Scott. I am Dr. Jackson Miller.’ He introduced himself to Henry’s mom. She told us the same story Natalie had told us. 

‘What about you, Henry?’ Jax turned to him again. ‘How are you feeling now?’

He shrugged. ‘My elbow is hurting.’

‘I see, let’s take a look at it.’ Jax motioned for them to follow him into an exam room. Since Henry hadn’t been admitted, they were waiting in the hall for the papers to go home. 

Henry laid down on the gurney and Jax started the physical. Henry’s elbows were swollen and had limited range of motion but they were not erythematous or warm. Jax tested other joints and Henry’s left hip was also painful. As the good pediatrician he was, Jax always examine his patients from head to toes. So he lowered Henry’s pants to assess his legs and there were some raised red spots on his skin. 

‘What about these, Mrs. Scott?’ He asked the mother.

‘Oh, I think these were just mosquito bites from the park. We were there all day until Henry fell off the swing.’

Jax asked Nat to come closer and told her to palpate the legs. ‘Can you feel them? This is palpable purpura.’ He explained. 

‘Mrs. Scott, I believe the best thing we can do now is to admit Henry. I don’t think his joint pain is from the fall and these red spots on his legs seem like little bleeds under the skin. I can’t say for sure what is causing these yet, but we need to run some tests.’

Jax and Nat answered some of the mother’s questions and we left. 

‘That purpura was really helpful.’ Jackson started. ‘Do you have any thoughts now, Nat?’

‘Hum… I am trying to remember where I saw that palpable purpura before.’ Nat scratched her head.

‘Henoch-Schonlein Purpura.’ Jax helped. ‘The IgA vasculitis. Besides the palpable purpura, It can cause joint pain and swelling. If I am right, his platelets and coagulation panel will be normal but we need to keep an eye on his renal function. Let’s order some basic tests and pass his case to the morning team.’

Natalie nodded silently.

‘Good job, Nat. Henry was lucky to have you.’

Jax and I got to the diner about 40 minutes later. 

‘That was impressive, Dr. Miller.’ He rolled his eyes. ‘I am serious, Jax. You are a great doctor.’

He smiled. ‘Thanks, Liz.’

‘So what now? For Henry.’

‘It usually resolves spontaneously, but we need to monitor him for complications. Depending on his labs he may need corticosteroids and ACE inhibitors.’

‘Keep me posted. I hope he gets better soon.’

Unfortunately, Jax told me Henry worsened the next week. He developed acute kidney injury and abdominal pain with intussusception and needed care in the ICU. Luckily he recovered after a couple more weeks and was discharged home.

        Since then, every time I see a patient fully clothed, I remember Henry.         What could be hidden under it?

Want to know more about Henoch-Schönlein purpura (IgA Vasculitis)?


Want to read a real case of Henoch-Schönlein purpura (IgA Vaculitis)?


Clinical Board

MC: most common; yo: year-old; URI: upper respiratory infection; PTC: platelet count; Coag: coagulation panel; ptnuria: proteinuria; Bx: biopsy; Tt: treatment; ACE-i: ACE-inhibitors.

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