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OpenAthens Shibboleth
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Special Feature
Nov 2012

Picture of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Pediatric Infectious Diseases (Dr Milder), Division of Infectious Diseases (Dr Gerber), The Children's Hospital of Philadelphia; Medical Corps, United States Navy, Naval Reserve Officer Training Corps (Dr Milder), and School of Medicine (Dr Gerber), University of Pennsylvania, Philadelphia.

Arch Pediatr Adolesc Med. 2012;166(11):1065. doi:10.1001/archpediatrics.2012.1687a

An 18-year-old woman reported to the emergency department after 2 weeks of having fatigue, poor appetite, and general malaise. She reported no fevers, rhinorrhea, vomiting, diarrhea, or rash. She had 2 days of diffuse joint pains in her upper and lower extremities, particularly in her ankles and wrists. While in the emergency department, she developed severe, acute right wrist pain with swelling, erythema, and warmth. A fluid-filled lesion developed on the dorsum of her right hand (Figure 1 and Figure 2). She was febrile (39.4°C) and tachycardic, with normal respiratory rate and blood pressure. Serum white blood cell count was 8400/mL; hemoglobin level was 9.0 g/dL (to convert to grams per liter, multiply by 10.0; reference range, 12.0-16.0 g/dL); and C-reactive protein level was 6.1 mg/L (to convert to nanomoles per liter, multiply by 9.524). Arthrocentesis of her right wrist revealed purulent fluid (white blood cell count, 95 000/mL).

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Figure 1. Photograph showing the fluid-filled lesion on the dorsum of the patient's right hand.

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Figure 2. Photograph showing swelling of the patient's right wrist. The adhesive bandage is covering the site where the arthrocentesis was performed.