LAUSR

A 13-year-old female with Turner syndrome presented to the emergency department reporting a 3-day history of left foot swelling and heel pain. Four days prior to presentation, she reported having nausea, several episodes of emesis, dizziness, and tactile fever. These symptoms had resolved within 24 hours of onset. Following the resolution of these symptoms, pain and swelling developed in her left hindfoot. These symptoms progressed over the 24 hours prior to medical evaluation, and she subsequently developed progressive pain, erythema, and swelling of the entire plantar aspect of the left foot. The patient had a history of intermittent bilateral lower extremity swelling, thought to be lymphedema in the setting of Turner syndrome. This lymphedema frequently involved the left foot greater than the right foot, and was exacerbated by increased activity such as walking or participating in dance classes. The current presentation of left foot swelling was inconsistent with her typical lower extremity swelling in its prolonged duration, pain, and accompanying erythema. The patient denied recent immobilization, falls, insect bites, or trauma to the foot. She did report a recent unusually long dance rehearsal in new, tight-fitting shoes, which she initially believed to be the cause of her prolonged foot pain and lower extremity swelling. Medical history was significant for a bicuspid aortic valve and mild aortic coarctation that did not require surgical intervention. Home medications included estrogen hormone supplementation, which began 4 weeks prior to presentation, and had been stopped on the day of presentation. On presentation, the patient appeared comfortable, though there was marked erythema and nonpitting edema of the plantar aspect of the hindfoot and midfoot, and medial aspect of the dorsal foot (Figure 1). Dorsalis pedis and posterior tibial arteries were easily palpable. There was no significant skin breakdown other than mild callous and flaking of the skin on the dorsum of the left third toe, near the interphalangeal joint. Pain was localized to the heel without radiation and only present on weightbearing. Pain was not reproducible with passive movement of the foot in dorsiflexion, plantarflexion, or inversion, with mild tenderness on eversion. The patient’s temperature was 37°C. White blood cell count was 10 620 cells/μL with 84% neutrophils and 6% bands. D-dimer was evaluated over concern for deep venous thrombosis and was not elevated. Venous Doppler ultrasound of the left lower extremity demonstrated no evidence of thrombus. X-ray imaging of the tibia, fibula, ankle, and foot did not show evidence of fracture, periosteal elevation, or bony erosion. Differential diagnosis included soft tissue infection, hypersensitivity reaction with edema (envenomation, sting), and tendinitis/overuse injury. The patient was 706150 CPJXXX10.1177/0009922817706150Clinical PediatricsMallipudi et al research-article2017