A child with back pain
A 4yr old girl presents complaining of back pain for the past week. Her parents report that whilst she is able to mobilise and sleep through the night without pain, sudden movements cause her to cry out. During this period, they report that she has also had a cough, lost her appetite and been more lethargic than usual. She has been afebrile and there is no history of trauma.
On review she is quiet but looks well. Her observations are within normal limits and she is afebrile. On respiratory examination she has reduced air entry throughout her left side, most pronounced at the base where she also has dullness to percussion. On examining her spine she has an obvious thoracic scoliosis with no midline tenderness. She has normal neurology in her legs and is able to jump.
A chest X-ray shows a moderate left sided pleural effusion with collapse/consolidation of the left lower lobe. The scoliosis is also evident with the convexity of the spine pointing to the unaffected right side.
1) Back pain in young children is a red flag
Back pain in children (particularly those 4yrs and under) is more likely to be due to a serious underlying condition than it is in adults. Have a high index of suspicion and think carefully before making a diagnosis of ‘Musculoskeletal back pain’.
2) Acute thoracic scoliosis – think pleural effusion
Thoracic scoliosis is a well-recognised clinical sign in children with pleural effusions. It is usually a transient process thought to be due to splinting of the chest wall to prevent pain.
3) Not every presentation is ‘textbook’ - think outside the box
Children with pneumonia often present atypically and may not have the classic respiratory signs of tachypnoea, hypoxia and increased respiratory effort. Remember the importance of percussion as part of your respiratory exam. When it comes to X-rays, it is important to remember that it takes time for the radiological signs of pneumonia to develop and so if there is good clinical suspicion we should still start antibiotic therapy.
Interested and want to learn more?
This case report published in 2018 describes the case of a 10yr old girl who initially presented with right sided abdominal pain but over the next few days developed an acute scoliosis which lead to the diagnosis of pneumonia with a parapneumonic effusion.
NB: Subtle changes have been made to this case to protect patient confidentiality
Dr Danielle Scarfe
Dr Danielle Scarfe