Presentation

A 3-year-old girl presented to the local emergency department with knee pain and recent refusal to walk. Six weeks prior, the patient had fever with rash and pain to the left knee. While the fever and rash quickly resolved, her pain persisted to the point that she now refused to walk or crawl. The patient had no significant past medical history, lives on a farm with farm and domestic animals, consumes unpasteurized milk and well water, and is not vaccinated by parental choice. 

In the ED, the patient was afebrile with no rash or erythema to the left knee, but mild joint effusions were noted. She had a normal white blood cell count, though her Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) were mildly elevated. The MRI suggested synovitis; osteomyelitis and abscess, so joint fluid, tissue and bone biopsy samples were surgically collected for culture prior to administration of empiric antibiotics. A cytology of the joint fluid showed 41,000 WBCs/μL with 91% neutrophils, but no organisms were seen on the sample Gram stains.

Routine aerobic and anaerobic bacterial, fungal and acid-fast bacilli cultures of the joint fluid, tissue and bone biopsy samples would ultimately be negative for growth following full incubation (4-42 days). The microbial etiology was only detected using non-culture-based molecular methods. 

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Author Information

Sophonie Jean Oyeniran, Ph.D., D(ABMM), Director, Antimicrobial Susceptibility Testing and Immunoserology, Nationwide Children’s Hospital, Assistant Professor, Department of Pathology, The Ohio State University College of Medicine.

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