Working Diagnosis:
Disseminated group A streptococcus bacteremia with associated calcaneal osteomyelitis, elbow cellulitis, and triceps tendinitis

Treatment:
Due to poor pain control and worsening pain, the patient was sent to the emergency room for further evaluation where labs and imaging were performed. The patient was admitted out of concern for sepsis and started on vancomycin and ceftriaxone but narrowed to IV penicillin after blood cultures were positive for group A streptococcus. He received 5 days of IV Penicillin with significant clinical improvement characterized by resolving pain and inflammatory markers. His repeat blood cultures were negative at 48 hours. He was then discharged with an additional three-week course of PO cephalexin with infectious disease (ID) follow up.

Outcome:
At his infectious disease follow-up appointment, he had been compliant with his antibiotics and denied new fever but was still not fully weight bearing. His heel swelling had reportedly decreased but had not fully resolved. His right elbow had completely healed. He continued to report point tenderness over the midpoint of his left heel. His WBC and inflammatory markers were trending down appropriately. MRI of his foot was repeated which showed worsening osteomyelitis of the entire calcaneus with extension across the calcaneal physis and apophysitis. Case Photo #6 His antibiotic course was extended for another 3 weeks.

At his last follow up, he had completed a total of 6 weeks of PO cephalexin and reported no issues with walking, no fever, and no heel pain. His heel exam was normal. His WBC and inflammatory markers were normal. Overall, it was determined his infection had resolved and his antibiotics were discontinued.

Author's Comments:
Author's Comments: Keep your differential diagnosis broad including infectious, oncologic, and rheumatologic causes, especially in a patient with intractable pain without a clear acute mechanism of injury. Always obtain a thorough review of systems especially regarding recent infections.

Editor Comments: The symptoms of strep throat can self resolve without antibiotics. This case highlights the importance of diagnosis and treatment of strep pharyngitis to prevent other potentially significant complications, osteomyelitis being one of the rarer ones. Pain out of proportion to exam and erythema/warm with limitation in range of motion of a joint are all red flags suspicious for an infectious etiology that warrant further evaluation in any joint evaluation. Symptoms in multiple joints also is a clue that there is a more systemic etiology at play.

Editor's Comments:
The symptoms of strep throat can self resolve without antibiotics. This case highlights the importance of diagnosis and treatment of strep pharyngitis to prevent other potentially significant complications, osteomyelitis being one of the rarer ones. Pain out of proportion to exam and erythema/warm with limitation in range of motion of a joint are all red flags suspicious for an infectious etiology that warrant further evaluation in any joint evaluation. Symptoms in multiple joints also is a clue that there is a more systemic etiology at play.

References:
1. Cassas KJ, Cassettari-Wayhs A. Childhood and Adolescent Sports-Related Overuse Injuries. afp. 2006;73(6):1014-1022.
2. Thakolkaran N, Shetty AK. Acute Hematogenous Osteomyelitis in Children. Ochsner J. 2019;19(2):116-122. doi:10.31486/toj.18.0138
3. Lima ALL, Oliveira PR, Carvalho VC, Cimerman S, Savio E. Recommendations for the treatment of osteomyelitis. Braz J Infect Dis. 2014;18(5):526-534. doi:10.1016/j.bjid.2013.12.005
4. Hatzenbuehler J, Pulling TJ. Diagnosis and Management of Osteomyelitis. 2011;84(9).
5. Castellazzi L, Mantero M, Esposito S. Update on the Management of Pediatric Acute Osteomyelitis and Septic Arthritis. Int J Mol Sci. 2016;17(6):855. doi:10.3390/ijms17060855
6. American Academy of Pediatrics. Group A Streptococcal Infections. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics: 2021. 694-707.

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