Chapter 5 Pain in infancy and childhood
Case 5.1
Case 5.2
4. You refer Josef to another doctor, who performs a number of tests. Which investigations do you think may have been done?
Investigations may have included:[1]
5. All tests are normal. What is the most likely diagnosis?
The most likely diagnosis is ‘pain disorder’ as a manifestation of a somatoform disorder.
6. Briefly describe some of the theories regarding the cause of this problem.
Problems in the first few months of life may — in some individuals — sensitise the gastrointestinal tract to pain in later years.[1]
Theories which attempt to explain somatoform disorders can be used to explain recurrent abdominal pain in children. These span a broad range of causes, including stress, trauma, abuse, emotions, social factors, biological factors, communication difficulties, learned behaviour, psychodynamic and ‘family systems’ theories.[2]
Case 5.3
1. What are the possible causes of his pain?
| Possible cause | Justification |
|---|---|
| Overuse syndromes (eg: stress fracture, Osgood-Schlatter disease, shin splints, Severe’s disease, condromalacia patellae) | Common in children who play sport |
| Rheumatoid conditions | Begin to appear at this age (4–10-year-olds) |
| Growing pains | Age of patient, pain at night, diffuse bilateral leg pain. It is a diagnosis of exclusion |
| Legg-Calve-Perthes disease | This commonly affects children between the ages of 4–8 years old and is five times more common in males than females[3] |
| Fractures, dislocations and ligamentous injuries | Trauma is the most common cause of acute limp in children.[3] In young children fractures are more common than sprains and strains.[3] Need to consider child abuse if the injury does not match the given history |
| Infections | At this age osteomyelitis commonly starts from the terminal vessels in the metaphysis of growing bones. Clinical signs include fever and systemic signs plus tenderness, redness, warmth and swelling. However, this condition is often monoarticular most commonly affecting the hip |
| Duchenne muscular dystrophy | Most common muscular dystrophy affecting 1 in 3500 males born worldwide. This clinically manifests in patients aged 3–7 years old. Clinical signs include increased lordosis, presence of Gowers sign and waddling/wide-stance gait[4] |
| Neoplastic lesions: leukaemia and Ewing sarcoma | This diagnosis would be more unlikely, but should be a consideration in a child with lower limb pain. Possible benign bone tumours at this age include osteiod osteoma and osteochondroma, and malignant bone tumour considerations are osteosarcoma and Ewing sarcoma. Leukaemia and metastatic neuroblastoma are systemic neoplastic diseases which may cause leg pain[5] |
2. What pertinent questions do you wish to ask?
• Is the pain getting progressively worse? (May indicate something more sinister like neoplasm, Duchenne muscular dystrophy.)
• Does Robbie have a limp? (Red flag in children! May indicate trauma, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, neoplasm, etc).
• Does Robbie have a fever, chills or other constitutional symptoms? (May indicate infection, septic arthritis, malignancies, juvenile idiopathic arthritis.)
• Is Robbie able to play and keep up with other children? (If unable to keep up with other children his age, this may indicate a congenital or developmental disorder; eg: Duchene’s muscular dystrophy.)
• When during the day is the pain present? (Growing pains are only present at night. Early morning stiffness may be an indication of juvenile idiopathic arthritis. Nocturnal pain may suggest bone neoplasms, osteoid osteoma or growing pains.)
• Does Robbie participate in competitive sports activities? (Possibility of overuse syndromes/stress fractures.)
• Is there any weakness in the legs? (May indicate neurological disorder or Duchenne muscular dystrophy.)
• Is Robbie’s gait affected? (Waddling or wide-based gait may indicate Duchenne muscular dystrophy; spastic gait may indicate upper motor neuron lesions.)
• Does Robbie have trouble standing from the seated position? (Presence of Gowers’ sign; sign of Duchenne muscular dystrophy.)
• Does Robbie bruise easily, or has he had any recent weight loss or bone pain? (May indicate neoplastic disease.)
Case 5.4
1. Using only this information, list the possible causes of Isha’s presenting symptom(s). Justify your answer.
2. Why was Isha asked about the association of her pain with food? What type of food in particular would have an association with right hypochondrial pain?
9. How would your differential diagnosis vary if:
12.
b What information in the microscopic section of gallbladder signifies presence of inflammation in the gallbladder?
