Working Diagnosis:
The patient was found to have MRSA bacteremia complicated by subperiosteal abscess. Intraoperative cultures were collected, which were also positive for heavy MRSA growth.

Treatment:
Vancomycin and ceftriaxone were started empirically. The patient was taken to the OR with pediatric orthopedic surgery for irrigation and debridement of the abscess. Blood cultures returned positive for MRSA.

Outcome:
The patient was discharged from the hospital on post-op day 2 on doxycycline for 4 weeks. Repeat blood cultures had no growth at 24 hours. He was readmitted to the hospital one day later due to repeat positive blood cultures from prior admission after 24 hours. He was started on Daptomycin, transitioned back to doxycycline after blood cultures had no growth at 48 hours, and discharged.

Return to activity
Two weeks after the patient's debridement, he was evaluated by pediatric orthopedic surgery in the outpatient setting. At that time, he was afebrile and remained on his antibiotic course. His pain and limp were improving, he had good range of motion of the hip, and he was permitted to continue advancing weight-bearing activity as tolerated.

Author's Comments:
Author's Comments
The causes of limp in children are broad and range from benign to life-threatening. Although the mechanism of this patient's hip injury seemed traumatic in nature, his tachycardia and fever raised concern for an infectious cause. Pelvic abscesses in children are commonly due to intra-abdominal surgery, injury, or perforations, which this patient did not have. His history was significant for a puncture wound on his heel after stepping on a bolt two weeks prior. The child also lived with two siblings, who had previously been colonized with MRSA. As MRSA may be transferred by skin-to-skin contact, it is possible that his puncture wound introduced the bacteria from his skin into the bloodstream.

Editor's Comments:
Pelvic abscesses in children with the lack of abdominal interventions or trauma is a rather uncommon clinical diagnosis. As the authors has stated, the differential for hip pain in adolescents is broad and requires a detailed history and physical examination to elucidate the etiology for the presentation. In this case, the patient's febrile status, history of foot puncture coupled with close exposure of MRSA were significant details in this case and further illuminates the need for a thorough history and physical examination. Lastly, the prompt response to send the patient for a elevated level of care was critical for the outcome of the patient.

References:
Long, Sarah S., and Kathryn M. Edwards. "Prolonged, recurrent, and periodic fever syndromes." Principles and practice of pediatric infectious diseases. Elsevier, 2012. 117-127.

Kocher, M S et al. "Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm." The Journal of bone and joint surgery. American volume vol. 81,12 (1999): 1662-70. doi:10.2106/00004623-199912000-00002

Habusta, Steven F., et al. "Septic Arthritis of the Pediatric Hip." StatPearls, StatPearls Publishing, 14 August 2023.

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