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Case 2: The accidental tourist.

A 10-year-old boy presented with a two-week history of progressive left elbow swelling, stiffness and achy pain. Before symptom onset, he had a minor fall at school and recalled knocking the same elbow against the ground, with no initial problems. He denied any fevers or systemic symptoms. His past history was unremarkable. His family had emigrated from the Philippines in 2005. 
 
On examination, the patient appeared well and was afebrile. His left elbow and distal humerus were swollen, with mild diffuse tenderness, and decreased flexion and extension. Warmth and erythema were not detected. The remainder of the examination was normal. Laboratory results showed a normal complete blood count, an erythrocyte sedimentation rate of 44 mm/h (normal 0 mm/h to 10 mm/h) and negative blood cultures after five days. Radiographs of his left elbow showed a large joint effusion and several lucencies in the distal humeral metaphysis (Figure 1). Joint aspiration revealed 5300×106/L white blood cells (24% neutrophils), with negative Gram stain and culture. The patient’s bone scan demonstrated increased flow in the distal humerus. His bone biopsy, before antibiotic therapy, was sent for stains and cultures for bacteria, fungi and acid-fast bacilli, which were all negative. Pathology showed a chronic inflammatory infiltrate and no granulomas. 
 
 
 
Figure 1 
 
Radiograph of the distal humerus at time of presentation, showing small metaphyseal lucencies, with cortical disruption and some periosteal reactions 
 
 
 
Several appointments were missed, and at presentation, five months had passed with worsening of symptoms despite 4.5 months of therapy. The patient continued to deny any systemic symptoms and only had left elbow swelling, stiffness and decreased range of motion. His physical examination appeared as described earlier. The radiographs showed ongoing disease progression (Figure 2). Laboratory results included an erythrocyte sedimentation rate of 107 mm/h and a white blood cell count of 10×109/L. 
 
 
 
Figure 2 
 
Radiograph repeated just before the second bone biopsy, showing ongoing destructive process into the proximal diaphysis 
 
 
 
Referral to the infectious diseases clinic resulted in further testing, revealing the diagnosis.