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Have Fever, Sore Throat And Bilateral Calf Muscle Pain. Medical Test Done. Any Ideas?

Posted on Thu, 9 May 2013

Question: 6 year old female, with high fever for > 3days, flu like symptoms, complaining of sore throat. Pharynx red,injected but no exudates. Tonsils not enlarged. Pt is alert communicative, appropriate behavior and now starts walking on tippy toes on occasions and complaining of bilateral calf muscle pain. Appears clinically fine but has an elevated CPK enzyme greater than 9,000. CBC: WBC: 3.2 H/H:12.7/37.5 Plts: 144. CRP:<0.2. Urinanalysis: wnl. Chemistry wnl: Na+ :144 K+: 4.2 chloride: 105 CO2: 22 Ca++: 8.7 AST:216 ALT: 216 ALT: 78 ALk. Phos: 207 BUN/Cr: 14/0.6. ASO titer-pending.
Any ideas ? Differential Dx? Further workup?

Answered by Dr. Muhammad Ishfaq Habib (1 hour later)

Hi
Welcome to XXXXXXX

Thank you for providing such detailed history along with reports.

The clinical presentation that have been provided is of pharyngitis with congested throat which is a throat infection that is causing fever. such condition requires antibiotic treatment along with decongestants like loratidine syrup that also relieve flu symptoms. The best antibiotic can be obtained by sending throat swab for culture and sensitivity. Paracetamol syrup can be used in case of high fever.

The second part of your question is based on the Lab reports you have provided. Almost all labs are within normal range except for CPK and ALT. The CPK is released from muscles and any inflammatory condition can raise them to high levels even exertional exercise or intramuscular injection can raise them to such levels. ALT is released from liver it should be below 45. There is a slight rise in ALT level which might either due to running infection or drugs that might have been used for fever.

It is recommended to repeat Liver function tests after 72 hours of these tests to assess the levels of ALT and Bilirubin also. If any abnormality detected, an ultrasound will be advisable.

If you still have some query, feel free to ask

Thanks
Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Muhammad Ishfaq Habib (12 hours later)

Is there a need to pursue the elevated CPK further other than rechecking it along with the LFT's later to make sure it's decreasing vs. increasing? Further workup for degenerative muscle disease necessary? Auto-immune etiology(connective tissue disease)? Hematologic/oncologic issues differential?

Answered by Dr. Muhammad Ishfaq Habib (19 hours later)

Thanks for the reply

I don't think so she could be having any degenerative muscle disease at this age. however recheck for CPK and LFTs would be helpful in identifying the disease progression or regression. I will recommend you to first treat the pharyngitis and then go for any further work up.

If you still have some query, feel free to ask

Thanks
Regards

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar