title: Extremity pain and refusal to walk in children with invasive meningococcal disease.
abstract: OBJECTIVE
  Early recognition of invasive meningococcal disease in children may be difficult. Extremity pain and refusal to walk (extremity symptoms) are uncommonly mentioned as clinical findings in children who present with this disease. We sought to determine 1) the frequency of extremity symptoms as part of the clinical presentation in children with invasive meningococcal disease and 2) whether these symptoms help identify children with otherwise unsuspected meningococcal disease.
  
  
  METHODS
  We reviewed the medical records of patients who were younger than 20 years and had invasive meningococcal disease from 1985 to 1996 at 3 pediatric referral centers. Children with extremity symptoms were identified and described. We compared clinical and laboratory findings and frequency of adverse outcomes between these children and those with invasive meningococcal disease without extremity symptoms.
  
  
  RESULTS
  We identified 274 children with invasive meningococcal disease, 45 (16%) of whom had either history or physical examination evidence of extremity pain (31) or refusal to walk (14) as part of their clinical presentations. Five of the 45 patients had arthritis at the time of presentation. Patients with extremity symptoms at presentation were significantly older (77.9 +/- 62.2 vs 44.0 +/- 56.9 months), had lower temperatures (38.8 +/- 1.2 degrees C vs 39.2 +/- 1.2 degrees C), and had higher band counts (28.2 +/- 15.2% vs 18.1 +/- 12.4%) than did patients without extremity symptoms. There were no significant differences, however, between groups with regard to rash, white blood cell counts, coagulation parameters, prevalence of meningitis, or adverse outcomes. Seventy-three (27%) of the 274 patients had unsuspected disease, and 5 (7%) of these had extremity symptoms at the time of diagnosis.
  
  
  CONCLUSIONS
  Sixteen percent of children with invasive meningococcal disease have extremity symptoms at the time of diagnosis. These symptoms may help to identify some patients with otherwise unsuspected invasive meningococcal disease.
authors.affiliation: Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California 90509, USA. inkelis@emedharbor.edu
authors.forename: Stanley H
authors.initials: SH
authors.lastname: Inkelis
authors.forename: Daniel
authors.initials: D
authors.lastname: O'Leary
authors.forename: Vincent J
authors.initials: VJ
authors.lastname: Wang
authors.forename: Richard
authors.initials: R
authors.lastname: Malley
authors.forename: Martha K
authors.initials: MK
authors.lastname: Nicholson
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
mesh_terms: D002648:Child; D005121:Extremities / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008297:Male; D008585:Meningitis, Meningococcal / Q000150:complications / Q000175:diagnosis* / Q000382:microbiology; D008589:Meningococcal Infections / Q000150:complications / Q000175:diagnosis* / Q000382:microbiology; D009345:Neisseria meningitidis / Q000302:isolation & purification; D010146:Pain / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D016138:Walking / Q000502:physiology