Twelve-year-old boy was brought by his mum to consult for recurrent itchy nostrils, fatigue and back pain.

The adolescent has a long-standing history of itchy and running nostrils since childhood. He sneezes a lot and has itchy nostrils in the presence of dust particles.There are no known factors of relief. Mum mentions the boy has frequently complained of fatigue, multi focal bone pain( in lower back, ribs, knee and hands) sometimes waking him up from sleep. The pains are temporarily relieved by Paracetamol tablets. Recently developed cough since about a week with green sputum. Persistence of all these led to the present consultation.
He is the 2nd child in a family of 4 (2 boys, 2 girls). His younger brother also complains of itchy nostrils. No known food or drug allergy. He develops nausea around strange odours.
Never been hospitalized. No other frequent illness apart from body pains. Immunization is not up to date since after free vaccines. Deworming was done over 3 months ago. Psychomotor development is normal for age. Mother’s Hb Electrophoresis is unknown. Father’s younger sister has sickle cell disease. No known chronic disease in parents.
On clinical exam, he has anorexia, fatigue and weight loss. Cough and rhinorrhea since about one week with green fluids produced. He has headache and polyphagia. Experiences enuresis, no dysuria. Passed out faeces 2 days ago, semi-solid.
He is well-looking. Stable vitals. His Sclerae are white, conjunctivae pink. Left tonsil slightly increased in size but no erythema nor tenderness. Tongue is coloured pink. No lymphadenopathy palpable. Chest is symmetrical. Vesicular breath sounds reduced around the base of right lung. Non-distended abdomen, no mass palpable. Limbs colored. No visible lesions on back. No tenderness on palpation of limbs and back. External genitalia with no anomalies seen.
Diagnosis was rhinobronchitis (and possibly atypical pneumonia) on a terrain to be investigated. First differential: Sinusitis. Though respiratory symptoms yet the usual body pain doesn’t fit there, so considered an underlying disease (terrain).
Malaria with early manifestations (headache, fatigue, body/joint pain)
Terrains discussed were a red blood cell anomaly (sickle cell disease, spherocytosis or symptomatic HbAS), Diabetes Mellitus probably Type 1.
Next differential rheumatic fever, or early stages HIV or Malignant tumoral syndrome with metastases.
An associated atopic terrain as well.
Lastly we considered possible atypical cystic fibrosis.
Glycemia, Urine dipstick analysis, Chest X-ray, Rapid Diagnostic test for malaria.
Hemoglobin electrophoresis, Full Blood Count with blood smear,
Anti streprolysin O test, HIV serology.

What do you think is his likely diagnosis? Please Share your questions and proposals here.

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3 responses to “Respiratory symptoms on chronic bone pain”

  1. NGNEPI DIOMO Justine Gisèle avatar

    Atopic rhenitis in a sickler

  2. TetuAl avatar

    Interesting case. I am not sure of what this kid has but I think Cystic fibrosis is far fetched after 12 years. Though a possible atypical form isn’t to be ignored. The green sputum points to an immune response to some lung infection. I would place him on a broad spectrum ATB.

    That itchy nose definitively points to an atopic terrain for me. I know this from personal experience. 🤣

    Guide the mother on how to find and keep him away from the triggers. It will do much good that drowsy – anti histamines.

    1. Germaine Mbange avatar

      I agrees Atopic Rhinitis is a diagnosis that should equally be brought up as his younger brother equally presents with frequent rhinitis

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Respiratory symptoms on chronic bone pain